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NERVOUS  AND  MENTAL 

DISEASES 


ARCHIBALD   CHURCH,   M.  D. 

PROFESSOR    OF    CLINICAL   NEUROLOGY   AND    OF    MENTAL    DISEASES    AND     MEDICAL   JURISPRUDENCE    IX 

THE    NORTHWESTERN  UNIVERSITY  MEDICAL  SCHOOL  (THE   CHICAGO    MEDICAL  COLLEGE), 

CHICAGO  ;      PROFESSOR      OF      NEUROLOGY     IN      THE      CHICAGO      POLICLINIC  ; 

NEUROLOGIST  TO  ST.  LUKE'S  HOSPITAL,  CHICAGO;    CONSULTING 

NEUROLOGIST     TO     THE     HOME     FOR     DESTITUTE 

CRIPPLED  CHILDREN,   CHICAGO,  ETC. 


AND 


FREDERICK   PETERSON,  M.  D. 

CLINICAL     PROFESSOR     OF     MENTAL     DISEASES     IN     THE    WOMAN'S     MEDICAL     COLLEGE,     NEW    YORK; 

CHIEF  OF  CLINIC,  NERVOUS    DEPARTMENT,   COLLEGE  OF  PHYSICIANS 

AND  SURGEONS,  NEW  YORK 


Witb  305  HUustrations 


PHILADELPHIA 

W.    B.    SAUNDERS 

925  WALNUT  STREET 
1899 


Copyright,  1899,  by  W.  B.  Saunders. 


CH 


PRESS   OF 
W.    B.   SAUNDERS 

PHILADA. 


PREFACE. 


This  book  has  been  written  for  medical  students  and  general  prac- 
titioners. It  makes  no  claim  to  be  other  than  a  carefully  prepared 
text-book.  The  literature  of  neurology  and  psychiatry  has  been  sifted 
by  the  authors,  and  such  digest  revised  in  the  light  of  their  own 
experience  in  practice  and  in  teaching.  They  have  attempted  to 
present  their  facts  clearly,  directly,  and  with  brevity,  despite  the  diffi- 
culty of  condensing  two  great  subjects  within  the  limits  of  a  single 
volume. 

This  is  not  the  joint  work  of  two  writers,  but  each  author — Dr. 
Church  in  Neurology,  and  Dr.  Peterson  in  Psychiatry — has  con- 
tributed to  the  making  of  a  single  volume  what  might  have  made 
a  separate  monograph  ;  each  is,  therefore,  solely  responsible  for  the  work 
in  his  own  department.  In  placing  the  correlated  sciences  neurology 
and  psychiatry  under  the  same  cover,  the  reader's  convenience  was 
considered. 

An  unusual  number  of  illustrations  for  each  department  (from  the 
authors'  own  material,  except  when  otherwise  indicated)  has  been 
allowed  by  a  generous  publisher. 


CONTENTS. 


NERVOUS  DISEASES. 

PART  I. 

PAGE 

Examination  op  Patients 17 

Chapter        I.  The  Anamnesis 17 

Chapter      II.  The  General  Physical  Examination 23 

Chapter     III.  The  Muscular  System 27 

Errors  of  Motility 27 

The  Reflexes 31 

Chapter     IV.  Trophic  Conditions 37 

Chapter       V.  Electrical  Conditions      39 

Chapter     VI.  Sensory  Conditions 48 

The  Tactile  Sense 49 

The  Pain  Sense         49 

The  Pressure  Sense 49 

The  Muscular  Sense 50 

Pain 55 

Chapter   VII.  The  Special  Senses      60 

Sight 60 

Hearing      63 

Smell 64 

Taste 64 

Chapter  VIII.  Speech 65 


PART  II. 

Diseases  of  the  Cerebral  Meninges  and  Cranial  Nerves 70 

Chapter        I.  Cerebral  Meninges      70 

Pachymeningitis 72 

Pial  Hemorrhage 74 

Chapter       II.  Inflammation  of  the  Pia  Mater 76 

Acute  Leptomeningitis , 76 

Chronic  Leptomeningitis 87 

Chapter     III.  Tubercular  Meningitis 88 

Chapter      IV.  Diseases  of  the  First  and  Second  Cranial  Nerves 94 

Chapter       V.  Diseases  of  the  Ocular  Nerves 102 

Chapter      VI.  Diseases  of  the  Trifacial  Nerve 109 

11 


12  CONTENTS. 

PAGE 

Chapter    VII.  Diseases  of  the  Facial  Nerve 114 

Chapter  VIII.  Diseases  of  the  Eighth  Cranial  Nerve 123 

Chapter     IX.   Diseases  of  the  Glossopharyngeal,  Vagus,  and  Accessory  Nerves     .  129 

Chapter       X.  Diseases  of  the  Spinal  Portion  of  the  Accessory  Nerve 140 

Chapter     XI.  Disease  of  the  Hypoglossal  Nerve 143 

Chapter  XII.  Multiple  Paralyses  of  Cranial  Nerves 145 


PART  III. 

Diseases  of  the  Beain  Peopee 155 

Chapter        I.  The  Cerebral  Cortex — Localization 155 

Chapter       II.  Speech  and  the  Cortex — Aphasia 164 

Chapter     III.  The  Cerebral  White  Matter,  Basal  Ganglia,  and  Cerebellum  .    .    .  174 

Chapter     IV.  Further  Localizing  Considerations 180 

Chapter       V.  Arterial  Brain  Diseases 185 

Chapter     VI.  Cerebral  Hemorrhage  and  the  Hemiplegic  State 195 

Chapter    VII.   Cerebral  Softening 210 

Chapter  VIII.  Diseases  of  the  Cerebral  Veins  and  Sinuses 219 

Chapter     IX.  Cerebritis,  Encephalitis,  and  Abscess  of  the  Brain 226 

Chapter      X.  Tumors  of  the  Brain 233 

Chapter     XL  The  Cerebral  Palsies  of  Children 245 

Chapter  XII.  Hydrocephalus 255 


PART  IV. 

Diseases  of  the  Spinal  Meninges  and  Spinal  Nerves 260 

Chapter        I.  Spinal  Meningitis  and  Spinal  Meningeal  Hemorrhage 260 

Chapter      II.  Injuries  and  Diseases  of  Spinal  Nerves 268 

Chapter    III.  Lesions  of  Special  Spinal  Nerves 278 

The  Cervical  and  Brachial  Plexuses 278 

Combined  Palsies  of  the  Nerves  of  the  Arm 285 

Nerves  of  the  Trunk 288 

Nerves  of  the  Lower  Extremity 288 

Chapter     IV.  Multiple  Neuritis 296 


PART  V. 

Diseases  of  the  Coed  Peopee 316 

Chapter        I.  Localization 316 

Chapter      II.  Indiscriminate  Cord  Lesions 330 

Chapter     III.  Lesions  and  Diseases  of  the  Spinal  Gray  Matter 356 

Chapter      IV.  Lesions  Affecting  the  White  Matter  of  the  Cord 389 

Tabes  Dorsalis      390 

Combined  Scleroses  of  the  Spinal  Cord 421 

Family  Ataxia 425 

Hereditary  Spastic  Paraplegia 431 

Sclerosis  of  the  Cord  Due  to  Vegetable  Intoxicants      432 


CONTENTS.  13 


PART  VI. 

Diseases  of  the  General  Nervous  System  with  known  Anatomical 

Basis 434 

Chapter        I.  Multiple  Cerebrospinal  Sclerosis 434 

Chapter      II.  Syphilis  of  the  Nervous  System 442 

Cerebral  Syphilis 444 

Spinal  Hyphilis 450 

The  Parasyphilitic  Diseases 154 


PART  VII. 

Diseases  of  the  Nervous  System  without  known  Anatomical  Basis    .  456 

Chapter        I.  Trophoneuroses 457 

Acromegalia 457 

Pulmonary  Hypertrophic  Osteoarthropathy 463 

Hyperostosis  cranii 464 

Myxedema 465 

Exophthalmic  Goiter      470 

Scleroderma 482 

Raynaud's  Disease 484 

Angioneurotic  Edema 486 

Localized  Hj^pertrophies 488 

Chapter      II.  Infection  Neuroses         490 

Tetanus      490. 

Hydrophobia 492 

Tetany «    .  495 

Chorea 499 

Chapter     III.  Motor  Neuroses 510 

Huntingdon's  Disease 510 

Myoclonia 511 

Dubini's  Disease  .    .    . 513 

Parkinson's  Disease,  Paralysis  Agitans 514 

Thomsen's  Disease  (Myotonia) 519 

Chapter     IV.  Fatigue  Neuroses 521 

Writers'  Cramp 522 

Other  Occupation  Neuroses 527 

Chapter       V.  Neurasthenia 528 

Chapter     VI.  Hysteria 538 

Stigmata  of  Hysteria 540 

Accidents  of  Hysteria 548 

Chapter   VII.  Epilepsy 565 

Chapter  VIII.  Migraine 577 

Chapter     IX.  Neuroses  following  Traumatism 581 

Chapter      X.  Tics 583 


14  CONTENTS. 


PART  VIII. 

PAGE 

Symptomatic  Disoedees , 586 

Chapter        I.  Neuralgia 586 

Chapter      II.  Disorders  of  Sleep 591 

Wakeful  Disorders  of  Sleep 593 

Somnolent  Disorders  of  Sleep 597 

Sleep  Palsies 598 

Hypnotism 598 


MENTAL   DISEASES. 

Chapter        I.  Definition  and  Classification  of  Insanity 603 

Chapter      II.  General  Etiology  of  Insanity ...610 

Sex      .    . 610 

Age 610 

Heredity 611 

Strain 634 

Chapter     III.  General  Symptomatology  of  Insanity 648 

Disorders  of  Sensation 649 

Disorders  of  Ideas 655 

Affective  Disorders 657 

Disorders  of  the  Idea-associations 660 

Disorders  of  Actions 669 

Accompanying  Physical  Disorders 671 

Chapter      IV.  Examination  of  the  Patient  ;  Diagnosis  ;  Course  of  the  Disease  ; 

Prognosis , 676 

Chapter       V.  General  Treatment  of  Insanity 680 

Treatment  of  Acute  Cases      685 

Chapter     VI.  Mania 694 

Chapter   VII.  Melancholia 700 

Chapter  VIII.  Circular  Insanity 711 

Chapter     IX.  Epileptic  Insanity 716 

Chapter       X.  Dementia 724 

Secondary  Dementia 725 

Senile  Dementia 726 

Primary  Dementia 728 

Chapter     XI.  Paralytic  Dementia 730 

Chapter    XII.  Paranoia  .    .    .    .  • 743 

Chapter  XIII.  Idiocy 767 


MENTAL  DISEASES 


FREDERICK  PETERSON,  M.  D. 


MENTAL  DISEASES. 


CHAPTER    I. 


INSANITY. 


Synonyms. — Psychosis,  Psychopathy.      German:  Irrsinn,  Irresein,  Verriicktheit, 
Wahnsiun.     French :  Alienatiuu  mentale,  Fulie. 

It  is  the  object  of  the  author  to  bring  together  in  the  following 
chapters  such  matter  in  relation  to  the  definition,  classification,  etiology, 
pathology,  symptomatology,  and  treatment  of  insanity  as  will  be  of 
actual  practical  value  to  the  medical  student  and  general  practitioner. 

The  seeker  after  special  information  and  deeper  knowledge  of  the 
complex  subject  of  morbid  psychology  must  be  referred  to  the  many 
profound  works  which  deal  with  this  exclusively.  These  chapters  are 
based  upon  my  clinical  lectures  given  at  the  Manhattan  State  Hospital 
for  the  Insane  and  at  the  Randall's  Island  Asylum  for  Idiots  during 
the  past  four  or  five  years,  to  the  students  of  the  College  of  Physicians 
and  Surgeons  of  Columbia  University,  and  to  the  students  of  the 
Woman's  Medical  College  of  the  New  York  Infirmary.  They,  there- 
fore, embody  only  the  facts  which  I  believe  to  be  the  most  serviceable 
and  useful  to  those  who  are  often  practically  concerned  with  the  early 
diagnosis  and  prognosis  of  insanity,  and  who  must  be  the  first  arbiters 
as  to  the  course  of  care  and  treatment  to  be  pursued. 

Definition. — The  difficulty  of  making  a  rigid  definition  of  insanity 
is  recognized  by  all  who  have  attempted  it.  So  various  are  the  mani- 
festations of  mental  aberration,  so  many  the  faculties  involved,  so  differ- 
ent the  degrees  of  deviation  from  the  normal,  it  is  no  wonder  that  the 
expert  hesitates  and  often  fails  in  the  effort.  The  definition,  too,  must 
include  idiocy,  and  must  exclude  certain  states  of  transitory  mental  dis- 
order, such  as  the  delirium  of  fevers  and  of  intoxications. 

The  noted  English  jurist,  Lord  Justice  Blackburn,  once  said,  while 
giving  evidence  before  a  committee  of  the  House  of  Commons  :  "  I 
have  read  every  definition  which  I  could  meet  with,  and  never  was 
satisfied  with  one  of  them,  and  have  endeavored  in  vain  to  make  one 
satisfactory  to  myself.  I  verily  believe  that  it  is  not  in  human  power 
to  do  it." 

Fortunately,  we  are  not  often  called  upon  to  give  a  definition  of 
insanity,  and   usually  we  may  reply  that  insanity  is  a  symptom  of  so 

603 


604  MENTAL   DISEASES. 

many  obscure  pathological  states,  and  appears  in  such  divers  forms  that 
a  narrow  definition  is  not  possible.  However,  the  practitioner  may 
find  himself  in  the  witness-box  some  day,  and  it  is  not  uncommon  for 
one  of  the  legal  examiners  to  ask  of  the  witness  in  a  mental  case  a  defi- 
nition of  insanity.  If  the  witness  be  wise,  he  will  answer  as  indicated, 
or  he  may  qualify  such  answer  by  offering  to  quote  some  one  of  the 
definitions  given  by  alienists,  such  as  follow  : 

A  disease  of  the  brain  (idiopathic  or  sympathetic)  affecting  the  in- 
tegrity of  the  mind,  whether  marked  by  intellectual  or  emotional  dis- 
order.— (Hack  Tuke.) 

A  special  disease,  a  form  of  alienation  characterized  by  the  acci- 
dental, unconscious,  and  more  or  less  permanent  disturbance  of  the 
reason. — (Regis.) 

Morbid  derangement,  generally  chronic,  of  the  supreme  cerebral 
centers, — the  gray  matter  of  the  cerebral  convolutions  or  the  intellecto- 
rium  commune, — giving  rise  to  perverted  feeling,  defective  or  erroneous 
ideation,  and  discordant  conduct,  conjointly  or  separately,  and  more 
or  less  incapacitating  the  individual  for  his  due  social  relations. — 
(Maudsley.) 

Insanity  is  either  the  inability  of  the  individual  to  correctly  register 
and  reproduce  impressions  (and  conceptions  based  on  these)  in  sufficient 
number  and  intensity  to  serve  as  guides  to  actions  in  harmony  with  the 
individual's  age,  circumstances,  and  surroundings,  and  to  limit  himself 
to  the  registration  as  subjective  realities  of  impression  transmitted  by 
the  peripheral  organs  of  sensation,  or  the  failure  to  properly  coordi- 
nate such  impressions  and  to  thereon  frame  logical  conclusions  and 
actions,  these  abilities  and  failures  being  in  every  instance  considered 
as  excluding  the  ordinary  influences  of  sleep,  trance,  somnambulism ; 
the  common  manifestations  of  the  general  neuroses,  such  as  epilepsy, 
hysteria,  and  chorea ;  of  febrile  delirium,  coma,  acute  intoxications, 
intense  mental  preoccupation ;  and  the  ordinary  immediate  effects  of 
nervous  shock  and  injury. — (Spitzka.) 

With  these  few  examples  before  us  of  the  diversity  of  definition 
attained  by  careful  students  of  psychiatry,  we  may  well  content  our- 
selves and  acknowledge  that  a  satisfactory  definition  in  brief  form  is 
scarcely  to  be  devised.  The  writer  has  often  qualified  this  by  offering 
the  following,  which  has  at  least  the  merit  of  brevity,  if  not  of  perfect 
adequacy  : 

Insanity  is  a  manifestation  in  language  or  conduct  of  disease  or  defect 
of  the  brain. 

The  law  assumes  to  offer  certain  definitions  of  insanity,  from  which, 
however,  those  of  medicine  would  tend  to  differ,  in  connection  with  the 
three  chief  points  where  law  and  psychiatric  medicine  meet : 

1.  A  criminal  is  insane  if  he  does  an  act  whose  nature  and  quality 
he  does  not  know,  or  if,  knowing  the  nature  and  quality  of  his  act,  he 
does  not  know  whether  it  is  right  or  wrong. 

2.  A  testator  is  insane  if  his  mind,  memory,  or  understanding  is 
unsound. 

3.  In  a  lunacy  inquisition  the  subject  of  the  inquiry  is  insane  if  he 


INSANITY.  605 

is  incapable  of  managing  himself  and  his  affairs.  Such  are  the  diver- 
gent tests  of  insanity  in  law. 

Classification. — What  has  been  said  of  the  difficulty  of  defining 
insanity  is  equally  applicable  to  classification.  Not  all  of  the  writers 
of  works  on  psychiatry  have  deemed  it  expedient  to  offer  a  definition 
of  insanity,  but  there  is  scarcely  one  who  has  not  presented  us  with  an 
original  classification,  or  one  modeled  upon,  or  modified  from,  that  of 
his  favorite  authority.  It  will  be  impossible  as  well  as  useless  to 
attempt  to  enumerate  in  these  pages  one-half  of  the  many  classifications 
which  have  been  made,  held  for  a  time,  and  finally  abandoned  with  the 
advance  of  science  and  the  accumulation  of  new  facts  in  the  domains 
of  pathology  and  psychology.  It  suffices  to  say  that  there  are  at  least 
forty  such  classifications  which  have  been  made  upon  etiological,  psy- 
chological, symptomatological,  or  pathological  grounds.  I  shall  present 
here,  simply  as  examples  for  reference,  several  of  the  latest  and  best 
classifications  of  the  Anglo-American,  German,  and  French  schools. 

The  Statistical  Committee  of  the  Medico-psychological  Association 
of  Great  Britain  adopted  the  following  classification  for  use  by  the 
medical  superintendents  of  asylums  : 

1 .  Congenital  or  infantile  mental  deficiency — 

a.  With  epilepsy. 

b.  Without  epilepsy. 

2.  Epilepsy  (acquired) . 

3.  General  paralysis  of  the  insane. 

4.  Mania — recent,  chronic,  recurrent,  a  potu,  puerperal,  senile. 

5.  Melancholia — recent,  chronic,  recurrent,  puerperal,  senile. 

6.  Dementia — primary,  secondary,  senile,  organic, — i.  e. ,  from  tumors,  coarse  brain 

disease. 

7.  Delusional  insanity. 

8.  Moral  insanity. 

Maudsley's  grouping  is  as  follows  : 

I.  Affective  or  Pathetic  Insanity. 

1 .  Maniacal  perversion  of  the  affective  life  (mania  without  delusion). 

2.  Melancholic  depression  without  delusion  (simple  melancholia). 

3.  Moral  alienation  proper  approaching  this,  but  not  reaching  the  degree 

of  positive  insanity  in  the  insane  temperament. 

II.  Ideational  Insanity. 

1.  General. 

a.  Mania. 

i  acute, 
chronic. 

2.  Partial. 

a.  Monomania. 

b.  Melancholia. 

{primary, 
secondary. 

4.  General  paralysis. 

5.  Imbecility. 


606 


MENTAL   DISEASES. 


Classification  of  the  Congress  of  Paris  (1889)  : 

1.  Mania  (acute  delirium). 

2.  Melancholia. 

3.  Periodical  insanity  (circular  insanity,  etc.). 

4.  Progressive  systematized  insanity. 

5.  Vesanic  dementia. 

6.  Organic  dementia. 

7.  Paralytic  insanity. 

8.  Neurotic  insanity  (hypochondria,  hysteria,  epilepsy,  etc.), 

9.  Toxic  insanity. 

10.  Moral  and  impulsive  insanity. 

11.  Idiocy. 

The  following  is  the  classification  of  Regis : 


I.  Functional  Insanity. 


Generalized 


symptomatic. 


].  Mania. 


2.  Melan- 
cholia. 


Subacute  mania  (maniacal  excitation). 
Acuta  mania  (typical  mania). 
Hyperacute  mania  (acute  delirium). 
Chronic  mania. 
Remittent  or  intermittent  mania. 

Subacute  melancholia  (melancholic   depres- 
sion). 
Acute  melancholia  (typical  melancholia). 
Hyperacute  melancholia  (with  stupor) . 
Chronic  melancholia. 
Remittent  or  intermittent  melancholia. 


Partial  or 
essential  insanity. 


( continuous. 
3.  Insanity  of  double  form  < 

( intermittent. 
First  stage  (hypochondriacal  insanity). 
Second  stage  (persecutory,  religious,  erotic, 

political,  etc.). 
Third  stage  (ambitious  insanity). 


Systematized 

progressive 

insanity. 


II.  Constitutional  Insanity. 

/  Disharmony  (defect  of  equilibrium,  irregularity,  eccentricity) 

Degeneracy  of    \  Neurasthenia  (fixed  ideas,  impulsions,  aboulias). 
evolution.         )  ( delusional. 

(Vices  of  or-      J  Phrenasthenias  \  reasoning. 
ganization. )      f  ( instinctive. 

\  Monstrosities  (imbecility,  idiocy,  cretinism,  myxedema). 
Degeneracy  of  in-      I 

volution.  \-  Dementia  (simple  dementia). 

(Disorganization.)     J 

Krafft-Ebing  has  drawn  up  this  scheme  : 


A.  MENTAL  DISORDERS  OF  THE  DEVELOPED  BRAIN. 
PSYCHONEUROSES. 


1 .  Primary  curable  conditions. 


{ simplex. 
Melancholia  i 

(  attonita. 

Mf  Maniacal  exaltation, 
ama.    i   a      , 

(  Acute  mania. 

Stupor,  or  curable  dementia. 

Wahnsinn  (vesania). 


INSANITY.  607 

I    Secondary  monomania  (Verriickthcit). 
f  agitated. 
Terminal  dementia  ^ 
(  apathetic. 
II.  Psychic  Degeneracies. 

1.  Reasoning  insanity. 

2.  Moral  insanity. 

3.  Primary  monomania  (prim'are  Verriicktheit — persecutory,    erotic,  reli- 

gious, ambitious). 

4.  With  imperative  conceptions. 

{epileptic, 
hysterical, 
hypochondriacal. 
6.  Periodical. 

III.  Cerebral  Diseases  with  Marked  Mental  Symptoms. 

1.  Paralytic  dementia. 

2.  Cerebral  syphilis. 

3.  Chronic  alcoholism. 

4.  Senile  dementia. 

5.  Acute  delirium. 

B.   ARRESTED  CEREBRAL  DEVELOPMENT. 

1.  Idiocy. 

2.  Cretinism. 

Ziehen  has  given  the  most  recent,  and  in  many  respects  the  best, 
classification  of  this  decad  : 

I.  Psychoses  without  Intellectual  Defect. 

A.  Simple  psychoses. 

Mania. 

1.  Affective  psychoses.         \    Melancholia. 

Neurasthenia. 

Stupidity. 

!  simple, 
hallucinatory, 
ideational  (ideenfliichtige). 
stuporous, 
incoherent. 
Imperative  conceptions. 

B.  Mingled  psychoses. 

II.  Psychoses  with  Intellectual  Defect. 

a.  Congenital  weakness  (idiocy,  imbecility,  feeble-mindedness). 

b.  Acquired  weakness,  or  dementia. 

1.  Paralytic  dementia. 

2.  Senile  dementia. 

3.  Secondary  dementia  (after  functional  psychoses). 

4.  Secondary  dementia  (after  cerebral  lesions,  syphilis,  etc.). 

5.  Epileptic  dementia. 

6.  Alcoholic  dementia. 

To  any  but  the  expert  and  special  student  some  of  these  classifica- 
tions must,  indeed,  be  mystifying  and  incomprehensible.  They  are  for- 
bidding to  the  ordinary  student  and  to  the  general  practitioner,  and 
might  well  induce  him  to  shun  the  realms  of  psychiatry  which  open 


608  MENTAL  DISEASES. 

before  him  so  uninvitingly  and  present  such  obstacles  to  his  progress. 
And  the  fact  is  that  they  are  interesting  to  the  specialist  alone  because 
they  are  as  yet  quite  impracticable  from  the  standpoint  of  actual 
utility,  as  is  evidenced  by  the  employment  even  by  the  physicians  of 
asylums,  who  are  nothing  if  not  practical  alienists,  of  far  simpler 
schemes  of  classification  in  the  preparation  of  statistics  for  their  annual 
reports  and  in  the  histories  entered  upon  their  case-books.  If  the  asy- 
lum practitioners  are  compelled  for  practical  purposes  to  adopt  a  simple 
method  of  classification,  how  is  the  novitiate  in  psychiatric  learning  to 
surpass  them  in  the  diagnosis  and  grouping  of  his  cases  ?  Here,  for 
instance,  is  the  latest  classification  for  statistical  purposes  made  for  the 
asylums  of  New  York  State  by  the  State  Commission  in  Lunacy 
(1897): 

Mania,  acute  delirious. 
Mania,  acute. 
Mania,  recurrent. 
Mania,  chronic. 
Melancholia,  acute. 
Melancholia,  simple. 
Melancholia,  chronic. 
Alternating  (circular)  insanity. 
Paranoia. 
General  paralysis. 
Dementia,  primary. 
Dementia,  terminal. 
Epilepsy  with  insanity. 
Idiocy. 

With  this  direct  evidence  of  the  practical  necessity  of  a  simple 
grouping  of  cases  into  forms  of  insanity  which  are  readily  distinguished 
from  one  another,  I  have  felt  that  I  could  not  do  better  in  my  teaching 
than  to  adopt  some  similar  arrangement.  It  took  me  a  long  time,  after 
beginning  a  residence  of  several  years  in  a  large  insane  asylum,  to 
crystallize  the  types,  which  were  at  first  very  confusing,  into  some  sort 
of  systematic  division.  The  student  or  practitioner  unfamiliar  with 
insanity  would,  upon  a  visit  to  a  large  institution,  probably  be  first 
struck  by  the  peculiar  shapes  of  heads  of  some  of  the  patients.  He 
would  find,  upon  inquiry,  that  the  cases  with  malformed  crania  were 
congenital  idiots,  imbeciles,  or  feeble-minded,  and  before  much  time  had 
elapsed  he  would  unconsciously  make  in  his  own  mind  the  two  great 
divisions  of  the  insane  into  those  with  diseased  brains  and  those  with 
defective  brains.  The  former  class  includes  the  brains  which  had  dev. 
oped  normally  for  years  and  had  then  fallen  a  prey  to  disease ;  the 
latter  the  brains  affected  by  congenital  defect  or  by  defect  acquired 
through  organic  diseases '  in  earliest  childhood.  In  other  words,  he 
would  separate  them  first  into  the  insane  proper  and  idiots.  The  term 
idiocy  comprises  three  degrees  of  mental  impairment — jyrofound  idiocy, 
moderate  defect  or  imbecility,  and  mere  weakness  of  mind,  or  feeble- 
mindedness. 

Now,  as  the  student  proceeds  to  study  the  physiognomy,  conduct, 
and  speech  of  the  cases  of  insanity  proper,  he  distinguishes,  ere  long, 
states  of  depression  (the  gloomy  visages  and  unhappy  ideas  of  melan- 


INSANITY.  609 

cholia)  and  states  of  exaltation  (the  ideomotor  exeitemenl  of  mania). 
Their  histories  will  tell  him  whether  they  arc  acute,  subacute,  chronic, 
or  recurrent,  and  whether  they  arc  puerperal,  lactational,  climacteric, 
senile,  epileptic,  hysterical,  toxic,  etc.,  in  their  origin.  A  very  .-mall 
percentage  of  cases  presents  the  curious  phenomena  of  alternating 
phases  of  mania,  lucid  intervals,  and  melancholia,  giving  the  entity  a 
cyclical  character,  and  these  rare  examples  of  mental  disorder  are  dis- 
tinguished as  circular  insanity. 

Epilepsy  is  found  in  a  considerable  proportion  of  the  inmates  of 
asylums, — sometimes  conjoined  with  idiocy,  sometimes  with  dementia, 
sometimes  with  symptoms  of  mania  or  melancholia,  and  often  present- 
ing peculiar  qualities  of  mental  disorder  which  render  the  subject  of 
epileptic  insanity  worthy  of  a  separate  chapter.  A  very  large  group  of 
patients  in  the  asylum  would  probably  impress  him  as  being  idiotic  or 
imbecile  by  their  speech  and  demeanor,  and  yet  he  would  observe  them 
)  have  normally  shaped  heads,  and  traces  of  old  intelligence  might  be 
manifest.  By  inquiry  into  the  histories  of  these  numerous  patients  he 
would  find  that  the  mental  enfeeblement  so  plainly  apparent  had  been  a 
sequel  to  a  serious  antecedent  brain-storm,  had  followed  upon  an  attack 
of  mania  or  melancholia,  and  that  the  designation  of  this  condition  is 
accordingly  secondary  or  terminal  dementia.  The  term  "  dementia  "  means 
in  psychiatry  enfeeblement  of  the  mind.  There  are  rare  cases  where 
such  enfeeblement  develops  ab  initio — e.  g.,  without  either  of  the  ante- 
cedent psychoses  just  described,  and  this  condition  is  entitled  primary 
dementia. 

Still  another  considerable  group  of  cases  becomes  distinct  upon  fur- 
ther study,  a  syndrome  identified  by  progressive  mental  enfeeblement, 
accompanied  by  progressively  increasing  paresis  or  paralysis  of  the 
muscles  of  speech,  of  the  face,  of  deglutition,  of  the  limbs,  in  fact  of 
the  whole  body, — dementia  paralytica,  general  paresis,  or  general  paraly- 
sis of  the  insane, — with  its  phases  of  grandiose  ideas,  tremor,  epilepti- 
form and  apoplectiform  episodes,  exaggerated  or  lost  knee-jerks,  and 
Argyll  Robertson  pupils. 

He  would  then  begin  to  be  puzzled  by  the  fixed  delusions  of  perse- 
cution and  grandeur,  especially  by  the  former,  which  he  would  encounter 
in  many  patients, — in  some  rather  confused,  weak,  and  transitory  ;  in 
others  systematized  into  a  most  elaborate  scheme,  with  considerable  logic 
and  intelligence.  Some  study  of  these  would  lead  the  student  to  place 
\e  less  elaborate  persecutory  ideas  among  the  melancholiacs,  alcoholics, 
etc.,  the  less  elaborate  grandiose  ideas  among  the  chronic  maniacs  and 
general  paretics,  while  the  wonderfully  elaborated  delusions  of  gran- 
deur and  persecution  of  paranoia  would  lead  him  to  recognize  under  this 
heading  the  remarkable  mental  disorder  known  to  the  Germans  as 
"  primare  Verrucktheit,"  to  the  English  as  chronic  delusional  insanity, 
and  once  familiar  to  us  by  the  rather  indefinite  term  of  monomania. 

I  shall  leave  for  discussion  under  separate  headings  any  further  sub- 
divisions that  seem  to  me  useful.  The  outline  just  given  must  serve 
the  purpose  of  a  foundation  upon  which  the  student  will  rear  such 
superstructure  as  his  time  and  inclination  may  permit.  Accordingly, 
39 


610  MENTAL  DISEASES. 

the  chapters   on  special   forms  of  insanity  in  this  book  will  be  simply 
arranged  as  follows  : 

1.  Mania. 

2.  Melancholia. 

3.  Circular  insanity. 

4.  Epileptic  insanity. 

5.  Dementia  (primary  and  secondary). 

6.  General  paresis  (paralytic  dementia). 

7.  Paranoia. 

8.  Idiocy,  imbecility,  and  feeble-mindedness. 


CHAPTER  II. 
GENERAL  ETIOLOGY  OF  INSANITY, 

The  proportion  of  the  insane  to  normal  individuals  may  be  stated 
to  be  about  1  to  300  of  the  population,  though  this  proportion  varies 
somewhat  within  narrow  limits  among  different  races  and  countries.  It 
is  probable  that  the  intemperate  use  of  alcohol  and  drugs,  the  spread- 
ing of  syphilis,  and  the  overstimulation  in  many  directions  of  modern 
civilization  have  determined  an  increase  difficult  to  estimate,  but  never- 
theless palpable,  of  insanity  in  the  present  century  as  compared  with 
past  centuries. 

The  amount  of  such  increase  might  easily  seem  to  be  large,  on  super- 
ficial examination,  because  of  the  imperfection  of  census-taking  in  the 
past,  the  accumulation  of  the  chronic  insane,  and  in  new  communities 
the  constant  upbuilding  of  new  asylums. 

Sex. — As  regards  sex,  women  and  men  are  about  equally  affected, 
for  the  particular  etiological  factors  determining  insanity  in  the  one 
(such  as  the  puerperal  period,  the  menopause,  etc.)  are  evenly  balanced 
by  the  special  causes  acting  upon  the  other  (struggle  for  existence, 
drunkenness,  syphilis,  etc.),  and  both  sexes  are  about  alike  in  their  sus- 
ceptibility to  the  two  great  etiological  elements  in  alienation  of  the  mind 
— heredity  and  mental  or  bodily  strain. 

Age. — The  question  of  age  is  of  great  importance  in  a  study  of  the 
etiology  of  insanity.  While  individuals  are  liable  to  mental  aberration 
at  any  age,  yet  there  are  particular  periods  of  life  characterized  by 
special  vulnerability.  In  general,  it  may  be  said  that  this  vulnerability 
is  greatest  in  women  between  the  ages  of  twenty-five  and  thirty-five, 
and  in  men  between  twenty  and  fifty,  for  it  is  at  middle  age  that  we 
find  the  maximum  accumulation  of  etiological  factors.  But  there  are 
physiological  epochs  that  influence  markedly  the  line  of  psychic  mor- 
bidity, and  these  are  the  periods  of  puberty  and  adolescence  (fourteen  to 
twenty  years),  that  of  genital  involution  in  women  (forty-five),  and  that 
of  senile  involution  (sixty  to  seventy  years). 

But  the  chief  factors  in  the  causation  of  insanity  may  be  summed  up 


GENERAL  ETIOLOGY  OF  INSANITY.  611 

in  two  words — heredity  and  strain.  The  former  is  responsible  for  in- 
stability of  the  nervous  system,  the  latter  is  multiform  in  character, 
comprising  all  of  the  stresses,  physical  and  mental,  direct  and  indirect, 
autochthonous  and  environmental,  which  may  undermine  the  nervous 
constitution  and  bring  it  to  its  point  of  collapse. 

Heredity. — In  determining  the  factor  of  heredity  we  must  not  be 
content  with  ascertaining  the  existence  of  psychoses  in  the  ascendants, 
but  must  seek,  by  careful  interrogation  of  various  members  of  the  family, 
for  some  of  the  hereditary  equivalents,  such  as  epilepsy,  chorea,  hys- 
teria, neurasthenia,  somnambulism,  migraine,  organic  diseases  of  the 
central  nervous  system,  criminal  tendencies,  eccentricities  of  character, 
drunkenness,  etc.,  for  these  equivalents  are  interchangeable  from  one 
generation  to  another,  and  are  simply  evidences  of  instability  of  the  ner- 
vous system.  It  is  the  unstable  nervous  organization  that  is  inherited, 
not  a  particular  neurosis  or  psychosis,  and  it  must  be  our  aim  in  the 
investigation  of  the  progenitors  to  discover  the  evidence  of  this. 

That  the  statistics  of  insanity  as  regards  heredity  are  often  faultily 
gathered  is  too  well  known.  In  the  first  place,  the  recorder  of  the 
history  of  a  patient  frequently  neglects  to  extend  his  inquiry  far  enough 
to  include  all  of  the  transmissible  psychoneuroses,  and,  in  the  second,  the 
relatives  are  prone  to  conceal  any  supposed  hereditary  taint  in  the 
family.  Here,  for  example,  is  a  table  prepared  by  the  Lunacy  Commis- 
sioners, showing  the  causes  of  insanity  in  136,478  admissions  to  asylums 
in  England  and  Wales,  in  which  I  find  the  item  "  hereditary  influence 
ascertained  "  20.5  per  cent.  Surely,  so  small  a  figure  does  not  represent 
the  true  proportion  of  heredity  as  an  etiological  factor  ! 

It  will  take  many  decads  of  much  more  careful  compilation  of  his- 
tories to  establish  the  actual  ratio,  but  we  shall  attain  nearer  to  the  facts 
year  by  year. 

No  one  has  better  formulated  the  principles  of  heredity  in  relation 
to  insanity  than  Mercier,1  who  points  out,  among  other  things,  that, 
besides  the  importance  of  the  direct  transmission  of  an  unstable  nervous 
system,  there  is  another  law  of  heredity,  which  is  known  as  the  law  of 
sanguinity.  Two  parents  may  be  perfectly  stable  and  have  normal  organ- 
isms, and  yet  produce  offspring  with  unstable  and  abnormal  nervous 
constitutions,  because  of  the  unsuitability  of  the  sexual  elements  of  the 
parents  to  each  other.  The  perfect  organization  of  the  progeny  is  the 
result  of  three  factors — the  quality  of  the  germ  (which  brings  matter), 
the  quality  of  the  sperm  (which  brings  force),  and  the  suitability  of  the 
one  to  the  other. 

The  laws  of  heredity  as  they  relate  to  insanity  may  be  summarized 
briefly  as  follows  : 

1 .  The  child  tends  to  inherit  every  attribute  of  both  parents. 

2.  Contradictory  attributes  can  not  be  inherited  from  both  parents. 

3.  The  child  may  inherit  the  attributes  of  either  parent  solely. 

4.  It  may  inherit  the  qualities  of  one  parent  in  some  respects  and 
of  the  other  in  other  respects. 

1  "Sanity  and  Insanity." 


612  MENTAL  DISEASES. 

5.  It  may  inherit  the  father's  attributes  for  one  period  of  existence 
and  the  mother's  for  another. 

6.  Some  attributes  have  the  quality  of  prepotency,  or  the  tendency 
to  push  aside  or  overrule  other  attributes. 

7.  Attributes  which  are  similar  in  both  parents  tend  to  become  pre- 
potent, giving  rise  to  convergent  or  cumulative  heredity. 

8.  Attributes  may  be  transmitted  in  latent  form  from  one  genera- 
tion to  another,  to  reappear  in  a  third  or  fourth  or  still  more  remote 
generation — a  phenomenon  termed  "  reversion." 

9.  Attributes  tend  to  appear  in  the  progeny  about  the  same  time  of 
life  at  which  they  became  manifest  in  the  parents. 

10.  Attributes  of  the  father  tend  to  be  inherited  by  the  sons  and  of 
the  mother  by  the  daughters. 

A  study  of  the  above  laws  will  explain  many  of  the  puzzling 
features  of  psychopathic  heredity, — why,  for  instance  often  only  a  few  of 
the  children  of  a  neurotic  parent  suffer  from  neuroses  or  psychoses,  and 
why  psychoneuroses  may  develop  in  the  progeny  of  healthy  parents 
(latency).  It  must  be  remembered,  too,  that  there  is  a  variation  in  the 
deoree  of  hereditary  taint  originated  by  the  several  heritable  equiva- 
lents. Thus,  simple  neurasthenia,  eccentricity  of  character,  and  a  puer- 
peral or  senile  psychosis  are  not  so  serious  a  heritage  as  epilepsy, 
chronic  alcoholism,  paranoia,  and  imbecility.  The  taint  in  a  family  is 
greater  the  larger  the  number  of  members  and  branches  afflicted. 
When  the  degree  of  hereditary  taint  is  marked,  the  psychoses  which 
may  develop  tend  to  be  modified  from  the  ordinary  types  of  such  psy- 
choses, and  this  deviation  is  termed  hereditary  degenerative  modifica- 
tion,— or,  in  short,  hereditary  degeneracy, — while  the  insanity  evolved  is 
designated  as  a  degenerative  psychosis.  The  particular  degenerative 
psychoses  are  such  forms  as  idiocy,  imbecility,  feeble-mindedness,  peri- 
odical and  circular  insanity,  hysterical  insanity,  acute  simple  paranoia, 
polymorphic  insanity,  etc.  A  polymorphic  course  is  particularly  char- 
acteristic of  psychic  degeneracy,  so  that  sometimes  a  perfect  chain  of 
psychopathic  conditions  and  psychoses  will  be  manifested  throughout 
the  life  of  the  degenerate. 

The  polymorphism  of  hereditary  transmission  sometimes  manifests 
itself  in  what  is  known  as  progressive  hereditary  degeneracy.  For 
example,  drunkenness  in  one  generation  may  lead  to  simple  psychoses 
in  the  next,  to  complex  degenerative  psychoses,  epilepsy,  etc.,  in  the 
third  generation,  and  finally,  in  the  fourth,  to  idiocy,  sterility,  and  the 
annihilation  of  the  stock. 

The  indications  of  degeneracy  in  an  individual  are  termed  the  stig- 
mata of  degeneration,  or  stigmata  hereditatis.  They  may  be  defined  as 
anatomical  or  functional  deviations  from  the  normal,  which  in  them- 
selves are  usually  of  little  importance  as  regards  the  existence  of  an 
organism,  but  are  characteristic  of  a  marked  or  latent  neuropathic  dis- 
position. Much  study  has  of  late  years  been  devoted  to  these  indices 
by  many  investigators,  particularly  in  their  relation  to  insanity,  idiocy, 
and  criminal  anthropology,  and  it  behooves  all  who  have  to  do  with  the 
development  and  care  of  the  human  body  in  any  particular — and  this 


GENERAL   ETIOLOGY  OF  INSANITY.  613 

refers  especially  to  men  of  the  medical  an<l  allied  professions — to 
familiarize  themselves  with  these  signs  of  degeneration,  in  so  far  as  they 
concern  their  own  special  provinces  of  work.  These  stigmata  are  vices 
of  functional  and  organic  evolution.  The  deviations  from  the  normal 
may  be  in  the  way  of  excesses  or  arrest  of  development.  They  must 
be  distinguished  from  the  deficiencies  or  deformities  produced  by  acci- 
dents at  birth  or  by  disease.  I  have  said  that  these  stigmata  are  ana- 
tomical and  functional,  but  it  is  more  convenient  to  divide  the  func- 
tional group  into  physiological  and  psychic  classes.  It  is  the  latter 
which  we  are  more  apt  to  observe  in  our  social  relations  with  degenerate 
individuals.  The  psychic  stigmata  are  always  characterized  by  want 
of  balance  or  lack  of  proportion  between  certain  undeveloped  or  exces- 
sively developed  faculties  and  other  faculties  which  are  normal.  De- 
fect of  moral  sense,  of  attention,  of  memory,  will,  judgment,  or  unbal- 
anced excess  of  musical  or  mathematical  aptitudes  may  be  cited  as 
instances  of  psychic  stigmata.  Hence  the  three  following  divisions 
may  be  made  of  all  the  degenerative  indices  :  (1)  Anatomical  stigmata  ; 
(2)  physiological  stigmata ;  (3)  psychic  stigmata. 

Anatomical  Stigmata. 
Cranial  anomalies. 
Facial  asymmetry. 
Deformities  of  the  palate. 
Dental  anomalies. 
Anomalies  of  the  tongue  and  lips. 
Anomalies  of  the  nose. 
Anomalies  of  the  eye  :  _ 

Flecks  on  the  iris  ;  strabismus  ;  chromatic  asymmetry  of  the  iris  ; 
narrow  palpebral  fissures. 

Albinism. 

Congenital  cataracts. 

Microphthalmos. 

Pigmentary  retinitis. 

Muscular  insufficiency. 
Anomalies  of  the  ear. 
Anomalies  of  the  limbs  : 

Polydactyly. 

Syndactyly. 

Ectrodactyly. 

Symelus. 

Ectroinelus. 

Phocomelus. 

Excessive  length  of  the  arms. 
Anomalies  of  the  body  in  general : 

Hernia?. 

Malformation  of  the  breasts,  thorax. 

Dwarfishness. 

Giantism. 

Infantilism. 

Feminism. 

Masculinism. 

Spina  bifida. 
Anomalies  of  the  genital  organs. 
Anomalies  of  the  skin. 

Polysarcia. 

Hypertrichosis. 

Absence  of  hair. 

Premature  grayness. 


614  MENTAL  DISEASES. 

Physiological  Stigmata. 

Anomalies  of  motor  function  : 

Retardation  of  learning  to  walk. 

Tics. 

Tremors. 

Epilepsy. 

Nystagmus. 
Anomalies  of  sensory  function  : 

Deaf-mutism. 

Neuralgia. 

Migraine. 

Hyperesthesia. 

Anesthesia. 

Blindness. 

Myopia. 

Hypermetropia. 

Astigmatism. 

Daltonism. 

Hemeralopia. 

Concentric  limitation  of  the  visual  field. 
Anomalies  of  speech  : 

Mutism. 

Defective  speech. 

Stammering. 

Stuttering. 
Anomalies  of  genito  urinary  function  : 

Sexual  irritability. 

Impotence. 

Sterility. 

Urinary  incontinence. 
Anomalies  of  instinct  or  appetite  : 

Uncontrollable  appetite  (food,  liquor,  drugs). 

Merycism. 
Diminished  resistance  against  external  influences  and  diseases. 
Retardation  of  puberty. 

Psychic  Stigmata. 
Insanity. 
Idiocy. 
Imbecility. 
Feeble-mindedness. 
Pavor  nocturnus. 

Precocity;  one-sided  talents  ;  disequilibration. 
Eccentricity. 
Moral  delinquency. 
Sexual  perversion. 

Having  made  this  attempt  to  classify  the  various  stigmata,  we  may 
now  proceed  to  examine  them  in  some  detail  r1 

Cranial  Anomalies. — The  most  important  features  to  be  noted  in 
connection  with  the  head  are  asymmetry  and  a  variety  of  deformities. 

1  For  further  information  on  these  subjects  the  reader  is  referred  to  the  following 
articles  by  the  writer  : 

"Some  of  the  Principles  of  Craniometry,"  "N.  Y.  Med.  Eecord,"  June,  1888. 

"Cranial  Measurements  in  Twenty  Cases  of  Infantile  Cerebral  Hemiplegia" 
(with  E.  D.  Fisher),  "  N.  Y.  Med.  Journal,"  April  6,  1889. 

"Craniometry  and  Cephalometry  in  Relation  to  Idiocy  and  Imbecility,"  "  Amer. 
Jour.  Insanity,"  July,  1895. 

"Deformities  of  the  Hard  Palate  in  Degenerates, "  "  Internat.  Dental  Journal, " 
December,  1895. 

"The  Stigmata  of  Degeneration,"  "  State  Hospitals  Bulletin,"  July,  1896. 


GENERAL    ETIOLOGY  OF  INSANITY. 


615 


It  is  necessary  to  an  understanding  of  these  stigmata  to  go  over  briefly 
a  few  facts  of  craniometry  and  cephalometry. 

A  score  or  more  of  distinguished  anthropologists  of*  the  present  cen- 
tury have  been  trying  to  discover  racial  distinction  in  human  skulls  ; 
but  the  fact  is  that  there  are  not  so  many  characteristics  of  race  in  the 
cranium  as  in  other  parts  of  the  body,  and,  accordingly,  there  are  still 
wide  differences  of  opinion  as  regards  a  scientific  craniological  classifi- 
cation. Races  have  been  mingling  so  many  thousands  of  years  that 
cranial  dissimilarities  are  the  rule  among  them,  even  in  tribes,  and  to 
some  extent  in  families.  These  diversities  of  form  have  been  designated 
as  dolichocephalic,  mesocephalie,  and  brachycephalic — words  which 
merely  convey  an  idea  of  the  relation  of  the  length  to  the  breadth  of 
the  skull  when  viewed  from  above.  The  anteroposterior  is  to  the 
biparietal  diameter  as  100  is  to  x,  is  the  formula  for  determining  this 
"  cephalic  index."  All  length-breadth  indices  below  78  are  considered 
dolichocephalic  ;  from  78  to  80,  mesocephalie ;  and  above  80,  brachy- 
cephalic. We  may  assume  that  the  physiological  limits  of  this  index 
are  70  to  90.     This  is  based  upon  thousands  of  measurements  of  skulls 


Fig.  236. 


by  various  investigators.  Any  excess  or  diminution  of  these  figures 
must  hence  be  regarded  as  pathological  (Fig.  236). 

But  while  one  skull  may  be  narrower  or  broader  than  another,  there 
is  compensation  in  other  diameters.  The  .dolichocephalic  has  a  greater 
vertical  diameter,  for  instance,  than  the  brachycephalic  skull. 

Besides  these  characteristics,  something  must  be  said  regarding  the 
physiological  asymmetry  of  the  skull.  The  fact  that  the  arms  and  hands 
are  not  symmetrical  on  the  two  sides  of  the  body,  either  in  size  or  func- 
tion ;  that  the  legs  and  feet  are  not  symmetrical ;  that  the  left  cerebral 
hemisphere  is  larger  and  more  complicated  than  the  right,  would  natu- 
rally lead  us  to  anticipate  some  slight  asymmetry  of  the  two  sides  of  the 
skull,  and  the  facts  of  observation  support  us  in  the  statement  that  asym- 
metry is  the  rule  and  perfect  symmetry  the  exception.  More  than  a 
thousand  postmortem  examinations,  the  examination  of  several  hundred 
heads,  and  an  inspection  of  some  collections  of  skulls,  such  as  that  of 
Blumenbach,  where  I  have  particularly  noted  this  point,  together  with 
the  testimony  of  others,  justify  me  in  this  assumption. 


616 


MENTAL   DISEASES. 


Asymmetry  sometimes  reaches  extraordinary  proportions, — often  with 
quite  a  normal  state  of  brain  function,  often  with  marked  psychopathic 
changes.  Outside  of  purely  physiological  asymmetry,  we  have  that 
depending  upon  defective  development  and  disease.  One  of  the  first  of 
nature's  constructive  principles  in  fashioning  the  skull  is  the  struggle 
of  its  contents  for  volume.  Hence,  as  long  ago  pointed  out  by  Vir- 
chow,  premature  synostosis  of  any  cranial  suture  will  lead  to  compen- 
satory deformity.     So,  too,  will  arrest  of  development  in  any  center  of 


Fig.  237. — Chemocephalus. 

ossification,  or  a  unilateral  aplasia  or  hyperplasia  of  the  skull  bones,  or 
of  the  contents  of  the  skull. 

Aside  from  the  deformities  of  the  head  which  are  congenital  in  char- 
acter, the  diseases  which  most  commonly  produce  cephalic  deformation 
in  early  life  are  rachitis  and  hydrocephalus  ;  in  later  life,  tumors,  exos- 
toses, etc.  ;  while  at  all  periods  of  life  the  shape  of  the  skull  is  menaced 
by  injuries,  from  a  forceps  delivery  to  a  falling  brick.  The  following 
are  some  of  the  commoner  designations  of  well-known  cranial  deformi- 
ties : 

Chemocephalus  is  flat-headedness.     In  this  there  is  flatness  at  the 


f1 


l 


Fig.  238. — Leptocephalus. 


top  of  the  head.  The  condition  is  also  called  platicephalus  (Fig. 
237). 

Leptocephalus. — Early  synostosis  of  the  frontal  and  sphenoid  pro- 
duces leptocephalus,  or  narrow-headedness  (Fig.  238). 

Macrocephalus  is  a  large  head,  usually  due  to  hydrocephalus. 

Microcephalus  is  a  small  head,  due  either  to  aplasia  of  the  brain  or 
premature  synostosis  of  the  sutures  (rarely  the  latter). 

Oxycephalus,  or  steeple-shaped  skull,  is  due  to  synostosis  of  the 
parietal  with  the  occipital  and  temporal   bones,  with   compensatory  de- 


GENERAL   ETIOLOGY  OF  INSANITY.  017 

velopment  in   the   region   of  the   bregma.      Another  name  for   this   \s 

otocephalus  (Fig.  239). 

Plagiocephalus,  or  oblique  deformity  of  the  head,  i.-  *lu<*  to  unilat- 
eral synostosis  of  the  frontal  with  one  of  the  parietal  bones  (Fig.  240). 

Scaphocephalies  is  probably  caused  either  by  too  early  union  of 
the  sagittal  suture  or  by  the  development  of  both  parietal  bones  from 
one  center.     The  top  of  the  head  is  keel-shaped  (Fig.  ~J.4\ ). 


Fig.  239.—  Oxycephalic. 


Fig.  240.— Plagiocephalus. 


Trig-onocephalus. — Premature  union  of  the  frontal  suture,  resulting 
in  very  narrow  forehead  and  great  width  behind,  giving  rise  to  the  term 
trigonocephalies  (Fig.  242). 

The  two  systems  of  measurement — the  eraniometrical  and  the  ceph- 
alometrical — differ  but  slightly  from  each  other,  the  former,  of  course, 
being  the  more  exact,  since  every  portion  of  the  naked  skull  is  attain- 
able. 

I  would   recommend  the  following  series  of  measurements  to  be 


Fig.  241.— Scaphocephalies. 


Fig.  242. — Trigonocephalus. 


taken — eleven  in  number — in  order  to  form  a  just  idea  of  the  capacity, 
shape,  and  symmetry  of  any  head  (Figs.  243  and  244):  (1)  The  circum- 
ference ;  (2)  the  naso-occipital  arc  (N  to  T)  ;  (3)  the  nasobregmatic  arc 
(N  to  fi)  ;  (4)  the  bregmatolambdoid  arc  (/5  to  A)  ;  (5)  the  binauricular 
arc  ;  (6)  the  anteroposterior  diameter  (S  to  0) ;  (7)  the  greatest  trans- 
verse diameter  (length-breadth  index) ;  (8)  the  binauricular  diameter ; 
(9)  the  two  auriculobregmatic  radii;  (10)  the  facial  length;  (11)  the 
empirical  greatest  height  (B  to  /5). 


618 


MENTAL  DISEASES. 


In  addition  to  acquiring  these  mathematical  data,  cephaloscopic 
drawings  are  invaluable  as  exhibiting  deformity  clearly  to  the  eye. 
Hence,  the  horizontal  circumference,  naso-occipital  curve,  and  binau- 
ricular  curve  should  be  taken  with  a  strip  of  lead,  or,  what  is  better, 
with  the  instrument  devised  by  Luys  (on  the  principle  of  the  hatter's 
conformateurs),  and  the  curves  projected  on  paper. 

Dolichocephalic  heads,  as  a  rule,  have  narrow,  and  brachycephalic 
have  broad,  faces.  Something  should  here  be  said  concerning  prog- 
nathism, of  which  there  are  several  forms.  The  best  method  of  deter- 
mining it  is  to  measure  the  angle  made  by  a  line  drawn  from  the  nasal 
root  to  the  junction  of  the  inferior  nasal  spine  and  alveolar  process 
(Fig.  244,  N  to  x)  with  a  vertical  line  dropped  from  the  nasal  root  to 
Broca's  horizontal.  It  is  found  that  every  normal  skull  exhibits  this 
subnasal  prognathism,  but  there  is  a  wide  variation  in  degree.  Extra- 
ordinary prognathism,  orthognathism,  and  opisthognathism — meaning 
extreme  projection,  straightness,  or  inclination  backward  of  the  sub- 
nasal  line — are  pathological. 

The  empirical  greatest  height  of  the  head  is  an  approximate  measure- 


BtNAUR/CULAR-D/AM-    ff. 
Fig.  243. 


Fig.  244. 


ment  of  the  distance  between  the  basion  and  vertex  of  the  skull  (B 
to  /?,  or  U).  A  line  from  the  external  occipital  protuberance  to  the 
lowest  median  point  of  the  superior  maxilla,  just  above  the  incisors  (T 
to  M ),  passes  almost  directly  through  the  basion.  Hence,  in  cephal- 
ometry,  by  taking  this  diameter  and  the  radii  from  each  extremity  to 
the  bregma,  we  have  a  triangle  (ill,  /5,  T)  whose  height  (B,  /?)  is  easily 
ascertained.  The  height  averages  13.3  cm.  in  men,  12.3  in  women, 
and  the  physiological  variation  is  from  11.5  to  15. 

The  only  instruments  necessary  for  obtaining  the  data  just  described 
are  a  pair  of  calipers,  the  tape-line,  and  a  strip  of  sheet-lead  two  feet 
long  by  \  or  f  of  an  inch  wide.  Benedikt's  calipers  (manufactured 
by  Wolters  in  Vienna),  which  are  here  illustrated,  are  to  be  recom- 
mended for  their  exactness  (Fig.  245),  as  are  also  those  that  I  have  had 
made  for  my  own  use  (Fig.  246). 

Excessive  prognathism  is  found  among  criminals,  in  microcephali, 
and  in  cases  of  hemi-  and  paraplegia  spastica  infantilis.  Skulls  known 
as  crania  progensea  have  considerable  pathological  significance.  In 
these,  lower  teeth  project  beyond  the  upper,  and  the  inferior  maxillary 


GENERAL   ETIOLOGY  OF  INSANITY. 


619 


angle  is  obtuse,  due,  probably,  to  aplasia  of  the  upper  or  hyperplasia 
of  the  lower  maxilla. 

The  demonstration  of  the  empirical  greatest  height  is  often  quite 
valuable  as  an  index  of  degenerative  and  neuropathic  types.  The 
following  are  some  general  points  which  should  be  considered  in  the 
examination  of  these  cases  : 

A  skull  below  the  normal  type  in  volume  belongs  to  an  abnormal 
individual. 

Undertypical  measurements  of  the  head  should  always  lead  us  to 
entertain  the  suspicion  of  defective  cerebration. 

Abnormal  smallness  of  any  part  of  the  skull  permits  the  conclusion 
that  the  part  of  the  brain  in  its  neighborhood  is  imperfectly  developed. 

Excessive  development  of  the  head  has  a  double  signification.     It  is 


r.r.T.T.r.T.T.TiT.T.f) 


Fig.  245.— Benedikt's 
calipers. 


Fig.  246. — Author's  calipers. 


always  pathological,  but  may  mean  abnormality  of  brain  or  successful 
compensation.  Wormian  bones  are  also  doubly  significant.  They 
either  represent  a  pathological  process  or  a  successful  effort  of  nature 
in  repair. 

Hemiplegia  spastica  infantilis,  epilepsy,  and  intellectual  or  ethic 
weakness  often  exhibit  unilateral  aplasia  of  the  skull. 

The  skull  is  representative  of  the  brain  only  during  the  years  of  its 
development,  and  it  must  be  remembered  that  psychopathic  deteriora- 
tion often  has  its  inception  subsequent  to  the  completion  of  the  process, 
when  no  impression  can  be  made  upon  its  bony  walls. 

I  have  prepared  a  table  of  the  measurements  recommended,  showing 
the  averages  in  adults,  male  and  female,  together  with  the  physiological 
variation,  excesses  above  or  below  which  are  significant  of  morbidity. 
It  is  based  upon  the  examination  of  some  hundreds  of  skulls  and 
heads,  and  upon  statistics  given  by  various  authorities  who  have  made 
especial  study  of  this  department  of  anthropometry.  Hence  it  may 
be  depended  upon  as  a  fair  estimate  of  the  dimensions  of  the  head  in 
most  of  the  Caucasian  races.     The  table  is  as  follows  : 


620 


MENTAL   DISEASES. 


Table  of  Ceaniometeicae  Measueements. 


Average  in 

Adult  in 

Centimeters. 

Physiolog- 
ical 
Variation. 

4) 

3 

Remarks. 

52 

50 

48.5-57.4 

Roughly  approximated,  the 
volume  is  to  the  circum- 

1500 

1300 

1201-1751 

ference  as  1350  c.c.  is  to 
50  cm. 

3.  Naso-occipital  arc,    .... 

32 

31 

28-38 

In  figure,  iVto  T. 

4.  Nasobregmatic  arc,          .    . 

12.5 

12 

10.9-14.9 

N  to  p. 

5.  Bregmatolambdoid  arc, 

12.5 

11.9 

9.1-14.4 

/3  to  A. 

6.   Binauricular  arc,      .        .    . 

32 

31 

28.4-35 

7.   Anteroposterior  diameter, 

17.7 

17.2 

16.5-19 

Sto  O. 

8.  Greatest  transverse  diameter 

14.6 

14 

13-16.5 

The  formula  for  the  length- 
breadth  index  is  : 

Length  :  Breadth  : :  100  :  x. 

An  index  below  78  is  doli- 
chocephalic ;  78  to  80, 
mesocephalic  ;  above  80, 
brachycephalic. 

9.   Length-breadth  index,     .    . 

82.2 

83.8 

76.1-87 

1 0.  Binauricular  diameter,    .    . 

12.4 

11.9 

10.9-13.9 

B           The   lieight 

A           B-X  of  the 

/  i  \         triangle    E, 

/        \       B,  E  formed 

Ff         '•        \p\\v  the  anri- 

11.  Auriculobregmatic  radii,    . 

A             culobregma- 
tic  radii  and  the  binauri- 
cular  diameter,  averages 
11.17    with    a    variation 
from  10  to  12.65. 

12.  Facial  length, 

12.37 

— 

10.5-14.4 

From  root   of  nose,  iV,  to 
lowest  part  of  chin. 

13.  Empirical  greatest  height, 

13.3 

12.3 

11.5-15 

The      empirical     greatest 
height,  B,  /3,  is  obtained 
by  measuring  the  sides  of 
the  triangle  M,fl,T. 

These  measurements  are  those  of  the  adult  human  skull.  As  the  hair  and  scalp 
superadd  about  3  cm.,  about  6  percent,  should  be  deducted  in  the  head  measurements 
Nos.  1,  3,  and  6  to  obtain  those  of  the  skull.  In  taking  the  diameters  Nos.  7  and  8, 
deduct  1  cm.  (the  scalp  averaging  5  mm.  in  thickness),  and  from  the  shorter  radii,  such 
as  Nos.  10  and  11,  subtract  but  7  mm. 


Facial  Asymmetry. — Inequality  of  the  two  sides  of  the  face — 
when  congenital  and  not  due  to  some  such  disease  as  hemiatrophy — is 
to  be  looked  upon  as  a  stigma  of  degeneration.  In  the  same  category 
may  be  grouped  various  irregularities,  and  such  conditions  as  excessive 
prognathism  or  retrognathism.     Great  prominence  or  unequal  promi- 


GENERAL   ETIOLOGY  OF  INSANITY. 


621 


oence  of  the  malar  bones  is  to  be  observed,  and  also  asymmetry  of  the 
orbits  ( Fig.  247). 

Deformities  of  the  Palate. — In  connection  with  the  soft  palate, 
bifurcation  of  the  uvula  may  be  mentioned.  As  regards  the  bard 
palate,  I  have  dwelt  upon  its  deformities  at  some  length  in  an  article  in 
the  "International  Dental  Journal"  (December,  1895),  and  the  facts 
there  brought  forward  may  be  recapitulated  as  follows  : 

While  the  palate  occupies  but  a  small  place  in  this  great  category  of 
hereditary  stigmata  of  all  kinds,  it  is  one  of  the  anatomical  group,  and 
this  group  is  for  many  reasons  the  one  of  greatest  importance.      In  this 


Fig.  247. — Male  epileptic,  aged  forty  years,  with  glabrous  face  and  chin  and  facial  asymmetry. 


group,  too,  it  occupies  a  distinctive  place  as  being  among  the   most 
striking,  frequent,  and  significant  of  the  anomalies. 

The  arch  of  the  hard  palate  presents  considerable  variation  within 
strictly  normal  anatomical  limits.  A  large,  wide,  moderately  high 
vault  is  what  may  be  called  a  normal  standard.  It  means  the  highest 
evolution,  judging  from  the  fact  that  the  mouth-cavity  increases  in 
capacity  as  we  ascend  the  vertebrate  series.  Deviations  from  that 
standard  are  not  at  all  infrequent,  and  yet  such  deviations  may  be  nor- 
mal. Thus,  the  palate  may  be  low  and  broad,  or  it  may  be  high  and 
narrow  ;  it  may  be  short  or  long  in  its  anteroposterior  diameter  ;  it 
may  be  ridged  unduly  along  the  palatine  sutures,  or  it  may  present 
marked  rugosities  on  its  surface,  especially  in  the  anterior  region ;  yet 
these  variations  are  normal.      Probably  we  may  look  upon  these  pecu- 


622  MENTAL   DISEASES. 

liarities  as  a  species  of  compensatory  development.  Just  as  in  a  study 
of  heads  we  find  some  very  long  and  low,  and  others  short  and  round 
and  high,  and  recognize  the  fact  that  the  shortness  in  one  dimension  is 
compensated  for  by  a  corresponding  increase  in  another,  so  we  may 
regard  variation  in  palatine  diameters. 

The  pathological  palate  has  not  been  studied  as  much  as  it  deserves 
to  be.  Save  occasional  and  casual  references  to  the  "  Gothic  "  palate 
in  literature,  and  one  or  two  papers  upon  the  "  torus  palatums,"  very 
little  has  been  written  upon  the  subject.  In  my  paper,  previously  referred 
to,  I  have  attempted  to  classify  such  pathological  palates  as  could  be  justly 
looked  upon  as  indicative  of  degeneracy.  The  word  Gothic  having  been 
so  long  in  use,  and  the  hard  palate  being  much  like  an  arch  or  roof,1  I 
have  followed  architectural  nomenclature  in  the  classification  offered. 

Pathological  Palates  : 

1.  Palate  with  Gothic  arch  (Fig.  248). 

2.  Palate  with  horseshoe  arch  (Fig.  249). 

3.  The  dome-shaped  palate  (Fig.  250). 

4.  The  flat-roofed  palate  (Fig.  251). 

5.  The  hip-roofed  palate  (Fig.  252). 

6.  The  asymmetrical  palate  (Fig.  253). 

7.  The  torus  palatinus  (Fig.  254). 

The  seven  varieties  named  are  to  be  looked  upon  as  types  merely. 
Each  type  will  be  found  to  present  variations  and  combinations  with 
other  forms.  Thus,  the  Gothic  arch  may  have  a  low  or  high  pitch  and 
be  short  or  long.  The  horseshoe  arch  (a  familiar  one  in  Moorish  archi- 
tecture) is  always  easily  distinguished,  but,  owing  to  its  conformation, 
a  cast  can  not  well  be  taken  of  it  to  show  it  in  a  perfect  outline.  The 
dome-shaped  palate  may  be  high  or  low,  may  be  combined  with  asym- 
metry or  torus.  The  presence  of  a  torus  in  the  Gothic  variety  is  apt  to 
destroy  the  purely  Gothic  form,  and  may  cause  it  to  resemble  the  flat- 
roofed  palate.  Under  the  heading  of  flat-roofed  palate  I  should  include 
all  such  palates  as  are  nearly  horizontal  in  outline,  as  well  as  those  with 
inclined-roof  sides  but  flattened  gable.  In  the  hip-roofed  palate  we 
have  the  sloping  sides  as  usual,  but  also  a  marked  pitch  of  the  palate 
roof  in  front  and  behind  ;  occasionally  one  may  meet  with  a  palate  of 
this  kind  with  so  remarkable  a  pitch  from  before  backward  that  it  is 
almost  like  a  Gothic  roof  turned  about  so  that  the  gable  runs  trans- 
versely. 

Asymmetry  in  the  palate  is  commonly  observed  in  many  of  the 
previously  described  forms,  but  occasionally  is  the  only  noteworthy 
peculiarity.  It  is  usual  to  find  asymmetry  of  the  face  and  skull  in 
cases  with  an  asymmetrical  palate.  The  torus  palatinus  (Latin  torus, 
swelling)  was  first  mentioned  by  Chassaignac  as  a  mediopalatine  exos- 
tosis. It  is  a  projecting  ridge  or  swelling  along  the  palatine  suture, 
sometimes  in  its  whole  length,  sometimes  in  only  a  portion  of  its  course. 
It  is  always  congenital.     It  varies  considerably  in  its  shape  and  size,  so 

1  "  There  is  some  confusion  in  literature  of  the  roof  of  the  mouth,  or  hard  palate, 
referred  to  in  this  paper,  with  the  dental  arch,  which  is  quite  another  thing." 


GENERAL   ETIOLOGY  OF  INSANITY.  623 

that  as  many  as  five  or  six  different  species  of  torus  are  recognized.  It 
may  be  wedge-shaped,  narrow,  broad,  very  prominent,  or  irregular.  J 
have  said  nothing  about  cleft-palate,  lor  I  am  not  sure  that  it  may  be 


Fig.  248.— Palate  with  Gothic  arch. 


Fig.  249. — Palate  with  horseshoe  arch. 


classed  among  the  well-marked  stigmata  of  degeneration.  I  have 
found  but  two  or  three  cleft-palates  among  the  450  idiots  and  imbeciles 
on  Randall's  Island,  while  a  number  of  cases  of  this  kind  with  which  I 


624  MENTAL   DISEASES. 

have  come  in  contact  in  my  professional  life  were  very  far  from  degen- 
erates. However,  it  would  seem  that  there  is  great  need  of  a  faithful 
study  of  a  large  number  of  cases  of  cleft-palate   in  relation  to  the  ques- 


Fig.  250. — The  dome-shaped  palate. 


Fig.  251.— The  flat-roofed  palate. 


tion  of  degeneracy.     The  deformed  palate  is,  to  my  mind,  one   of  the 
chief  anatomical  stigmata  of  degeneration. 

It  is  true  that,  from  this  single   indication,  it  would   not  be  strictly 


GENERAL  ETIOLOGY  OF  INSANITY. 


625 


scientific  to  adjudge  an  individual  a  degenerate.  Occasionally,  perhaps, 
a  case  presents  itself  where  this  anatomical  stigma  alone  would  suffice 
to  insure  a  diagnosis  of  this  nature  ;  but  usually  other  stigmata  coexist, 
such  as  cranial  anomalies,  deformities  of  the  ear,  and   the   like.     The 


Fig.  252.— The  hip-roofed  palate. 


Fig.  253. — The  asymmetrical  palate. 


frequency  of  the  pathological  palate  among  marked  degenerates,  such  as 
the  insane,  idiots,  and  epileptics,  has  been  testified  to  by  many  investi- 
gators. Thus,  Talbot  reported  43  per  cent,  of  abnormal  palates  in 
1605  inmates  in  institutions  for  the  feeble-minded.  Ireland  makes 
it  nearer  50  per  cent.  Charon,  a  later  writer  than  these,  found  abnor- 
40 


626  MENTAL  DISEASES. 

mal  palates  in  10  per  cent,  of  apparently  normal  persons,  in  82  per 
cent,  of  idiots  and  feeble-minded,  in  76  per  cent,  of  epileptics,  in  80  per 
cent,  of  cases  of  insanity  in  general,  in  70  per  cent,  of  the  hysterical 
insane,  and  in  35  per  cent,  of  cases  of  general  paralysis.  Nacke  has 
studied  particularly  the  torus  palatums  in  1449  individuals,  normal  and 
psychopathic;  he  found  it  present  in  23.9  per  cent,  of  psychopathic 
women  (insane,  epileptic,  idiot,  and  criminal),  32.9  per  cent,  of  epilep- 
tic women,  34.4  per  cent,  of  criminal  women,  22.7  per  cent,  of  normal 
women.  The  percentages  were  smaller  in  men  than  in  women.  A 
narrow  torus  is  more  common  than  a  broad  one. 

Stieda  examined  1500  skulls  for  the  torus  from  an  anthropological 
point  of  view.  The  skulls  were  of  Prussians,  Armenians,  Africans, 
Frenchmen,  Russians,  and  Asiatics.  He  decided  that  it  has  no  anthro- 
pological significance  ;  gives  no  racial  distinction.     While  the  torus   is 


Fig.  254.— Torus  palatinus  (broad,  wide  torus). 

undoubtedly  of  value  as  an  index  of  degeneration,  particularly  where  it 
is  well  marked,  it  probably  has  less  importance  in  this  respect  than 
some  of  the  other  forms  of  pathological  palate. 

Dental  Anomalies. — Among  anomalies  of  the  teeth  are  macro- 
dontism,  microdontism,  projecting  teeth,  badly  placed  or  misplaced 
teeth,  double  row  of  teeth,  or  teeth  which  are  striated  transversely  or 
longitudinally.  Caries  of  the  teeth  and  Hutchinson's  teeth  are  due  to 
neglect  or  disease.  The  latter,  however,  may  often  be  considered  as  a 
stigma  of  degeneration.  Then  there  is  a  retardation  of  the  first  and 
second  dentition. 

Anomalies  of  the  Tongue  and  Lips. — A  very  large  tongue 
(macroglossus)  is  not  infrequently  observed  among  the  lowest  classes  of 
degenerates,  as  in  idiocy.  Sometimes  there  is  microglossus,  asymmetry 
of  the  two  halves,  or  bifidity  of  the  point.  Harelip  is  somewhat  more 
common  than  cleft-palate,  but,  like  the  latter,  its  exact  standing  as  a 


GENERA  I,    ETIOLOGY  OF   INSANITY.  627 

degenerative  stigma  is  not  fully  determined.  Undue  swelling  or 
puffiness  of  the  lips  is  noteworthy. 

Anomalies  of  the  Nose. — Marked  deviation  of  the  nose  to  one 
side  or  the  other  should  be  noted.  Taken  alone  it  may  possess  Little 
significance,  but  in  conjunction  with  other  stigmata  it  is  of  value.  The 
nose  may  be  absent,  or  present  defect  of  osseous  development  (nasus 
adwncus)  or  atresia  of  the  nasal  fossa;. 

Anomalies  of  the  Eye. — The  pathological  conditions  of  the  eye 
have  been  placed  in  two  groups  in  the  foregoing  classification,  since  some 
are  anatomical  and  some  physiological.  To  enumerate  them  altogether, 
they  are  as  follows  : 

Anatomical.  Physiological. 

Flecks  on  the  iris.  Blindness. 

Strabismus.  Myopia. 

Chromatic  asymmetry  of  the  iris.  Hypermetropia. 

Narrow  palpebral  fissures.  Astigmatism. 

Albinism.  Daltonism. 

Congenital  cataracts.  Hemeralopia. 

Pigmentary  retinitis.  Concentric  limitation  of  the  visual  field. 

Microphthalmos.  Nystagmus. 

Muscular  insufficiency. 

It  is  true  that  any  one  or  two  or  more  of  these  conditions  present  do 
not  certainly  indicate  degeneracy,  but  they  are  significant  in  connection 
with  other  abnormal  states,  and  all  of  them  are  more  frequently 
observed  in  degenerate  individuals,  especially  the  lower  orders,  than  in 
normal  persons.  In  idiots,  convergent  strabismus,  due  to  defect  of 
refraction  and  in  conjunction  with  hypermetropia,  is  very  common. 
Muscular  insufficiency  and  nystagmus  (lateral  or  rotatory)  are  also  often 
met  with  in  this  class  of  cases.  In  paralytic  and  other  idiots  and  imbe- 
ciles homonymous  hemianopsia  is  sometimes  met  with. 

Anomalies  of  the  Ear. — Deformities  of  the  ear  have  been  de- 
servedly well  studied,  for  as  stigmata  of  degeneration  they  take  high 
rank,  like  anomalies  of  the  hard  palate,  in  the  anatomical  group. 
Morel,  Stahl,  Wildermuth,  Binder,  and,  more  recently,  Schwalbe,  have 
given  us  especially  good  studies  of  these  conditions.  From  their 
writings  and  my  own  studies,  the  following  classification  (following 
Binder)  into  twenty-two  varieties  may  be  made  : 

I.  Abnormally  implanted  ears  ;  they  project  too  far  or  lie  too 
closely,  are  placed  too  high  or  too  low,  too  far  forward  or  too  far 
backward  on  the  head. 

II.  Excessively  large  ears  :  (1)  absolutely  too  large  ;  (2)  rela- 
tively too  large  in  small  or  microcephalic  individuals. 

III.  Ears  which  are  too  small. 

IV.  Too  marked  conchoidal  shape  of  the  ear.  The  details  of  the 
ear  (anthelix  and  crura,  etc.)  are  but  slightly  marked,  while  the  helix 
outlines  the  ear  like  the  rim  of  a  funnel. 

V.  Ears  which  have  a  general  ugly  shape.  The  breadth  of  the 
upper  part  may  exceed  that  of  the  lower,  and  vice  versa ;  excessive 
length  ;  ears  without  lobules  ;  unusually  short  ears. 


628 


MENTAL   DISEASES. 


VI.     Ear  not  uniform  in  width  ;  usually  a  long  ear  with   one 
or  more  constrictions  in  its  breadth. 

VII.  The  Blainville  ear ;  asymmetry  of  various  kinds  of  the 
two  ears.  In  most  cases  the  asymmetry  is  due  to  an  anomaly  of  the 
left  ear. 


Fossa  ovalis 


Fossa  cymbae 


Fossa  concha 


Incisura  intertragica 


Fig.  255. — Normal  ear. 


Fossa  scaphoidea 


VIII.  The  ear  without  lobule ;  there  are  usually  other  deformities 
of  this  ear  besides  the  absence  of  lobule,  such  as  too  large  a  concha, 
prominence  of  the  anthelix,  etc. 

IX.     The  ear  with  adherent  lobule  ;  the  lobule  is  enlarged,  ad- 
herent, and  inclines  downward  toward  the  cheek. 


Fig.  256. — Blainville  ear;  also  excessive  length 
of  ears. 


Fig.  257.— Morel  ears. 


X.     The  Stahl  ear,  No.  I.1     A  series  of  anomalies  of  the  helix. 
The  helix  is  broad,  like    a  band,  and    coalesces  with   the    cartilages 


1  See  "  Zeitschriffc  fur  Psych.,"  vol.  xvi. 


GENERAL   ETIOLOGY  OF  INSANITY. 


629 


of  the  crura  furcata.  The  fossa  oralis  and  fossa  scaphoidea  are 
scarcely  to  be  seen.  The  lower  half  of  the  helix  is  obliterated.  There 
are  occasionally  slight  variations  from  this  type. 

XL  The  Darwin  ear  ;  helix  interrupted  where  its  transverse 
portion  passes  into  the  descending,  and  at  this  point  is  a  projection  of 
the  rim  above  and  outward,  like  the  pointed  ear  of  lower  animals. 

XII.  The  AVildermuth  ear.1  The  anthelix  projects  so  far  as 
to  form  the  most  prominent  part  of  the  auricle. 

XIII.  The  ear  without  anthelix  or  crura  furcata. 

XIV.  The  Stahl  ear,  No.  2.  Multiplication  of  the  divisions  of 
the  crura  furcata,  so  that  there  are  three  instead  of  two  crura. 

XV.  Wildermuth's  Aztec  ear.  Lobule  wanting ;  the  whole 
ear  seems  pushed  forward  and  downward  ;  the  crus  superius  of  the 
anthelix  coalesces  with  the  helix,  while  its  crus  anterius  is  scarcely 
perceptible. 

XVI.  The  Stahl  ear,  No.  3.  Only  the  crus  anterius  of  the  crura 
furcata  is  present,  while  the  auricle  seems  divided  into  two  halves  by  a 
ridge  from  the  antitragus. 

XVII.     The  ear  with  double  helix. 


Fig.  258.— Stahl  ear,  No.  1. 


Fig.  259. — Darwin  ear. 


XVIII.     The  ear  with  too  large  or  too  small  a  concha. 

XIX.  The  ear  with  continuous  fossa  scaphoidea.  The  fossa 
passes  down  into  the  lobe. 

XX.  The  Morel  ear.  A  form  marked  by  abnormal  develop- 
ment of  the  helix,  anthelix,  fossa  scaphoidea,  and  crura  furcata,  so  that 
the  folds  of  the  ear  seem  obliterated,  and  the  ear  is  smooth,  larger  than 
usual,  often  prominent,  and  with  thin  edge. 

XXI.  Ears  misshapen  by  abnormal  cartilage  development. 
Here  belong  all  irregular  cartilaginous  growths  and  thickenings  except 
those  caused  by  hematoma  of  the  ear. 

XXII.  Various  peculiarities,  difficult  to  classify,  are  included 
here,  such  as  abnormalities  of  the  semilunar  incisure  of  the  tragus  and  of 
the  meatus,  coloboma  of  the  lobule,  hairiness  of  the  different  parts  of 
the  auricle,  accessory  ears,  clefts,  etc. 


1  "Wurt.  Corresp.-Blatt,"  1886,  No.  40. 


630 


MENTAL   DISEASES. 


The  most  important  malformations  of  the  ear — those  that  may  be 
regarded  as  belonging  to  the  stigmata  of  degeneration,  and  those,  too, 
which  are  striking  and  plain  to  the  eye — are  to  be  summarized  as 
follows  : 

The  deep  position  of  the  crus  anterius. 

Marked  prominence  of  the  anthelix. 

Excessive  broadening  of  the  ear. 

Stunted  development  of  or  absence  of  the  helix. 

Trifurcation  of  the  anthelix. 

Widening  of  the  fossa  scaphoidea. 

Absence  of  the  eras  superius. 

Complete  absence  of  lobule. 

Asymmetry  of  the  two  ears. 

Excessive  enlargement  or  diminution  of  the  concha. 

Excessive  conchoidal  structure  of  the  ear. 

Reference  is  occasionally  made  in  literature  to  the  Cagot  ear.  The 
Cagot  is  a  species  of  cretin  in  the  French  and  Spanish  Pyrenees,  in 
which  one  of  the  chief  physical  deformities  is  absence  of  the  lobule  of 
the  ear. 

Binder  states  that  the  adherent  lobule  exists  in  almost  one-third  of 
normal  persons,  and  in  the  photographs  of  several  hundred  distinguished 
persons  15  per  cent,  had  abnormal  lobules.     At  the  same  time  more 


Fig.  260. — Excessive  length  of  ears;  facial  asymmetry. 


than  twice  as  many  adherent  lobules  are  found  in  degenerates  as  in 
normal  individuals. 

Now,  with  regard  to  statistics  of  malformed  ears  in  degenerate  in- 
dividuals, Wildermuth  noted  this  condition  in  41  per  cent,  of  142  idiots. 
Binder  found  64  per  cent,  of  degenerate  ears  in  354  insane  persons. 
It  is  to  be  remarked,  however,  that  Binder  was  more  careful  in  his  ex- 
aminations, and  by  long  practice  had  acquired  more  expert  knowledge 
than  Wildermuth.  Frankel  observed  degenerate  ears  in  29  cases  out 
of  32  with  cranium  proganseum. 

Knecht  found  20  per  cent,  of  degenerate  ears  among  1274  criminals, 
27  per  cent,  among  48  epileptics,  and  32  per  cent,  among  84  insane. 


OFNFAIAL    ETIOLOGY  OF   INSANITY. 


631 


Hinder  noted  degenerate  ears  in  33  persons  outside  of  institutions, 
supposed  to  be  normal  individuals.  Enquiring  closely  into  their  his- 
tories, he  discovered  that  7  of  them  had  insane  parents,  brethren,  or 
children;  in  19  there  were  decided  psychic  abnormalities,  and   only   7 


Fig.  261. — Broad,  baud-like  helix ;  no  ant- 
helix  ;  no  lobule ;  excessive  size  of  fossa  cym- 
bse. 


Fig.  262. — Excessive  length  of  ear  ;  fusion 
and  distortion  of  helix,  anthelix,  antitragus,  and 
lobule. 


Fig.  263. — Triplication  of  crura  furcata ;  mal- 
formed helix  and  antitragus ;  absent  lobule. 


Fig.  264.— Fissure  in  anthelix;   slight  Darwin 
tubercle ;  slight  antitragus. 


Fig.  265. — No  crus  superius ; 
no  anthelix ;  small  fossa  con- 
chse ;  few  details  of  ear. 


Fig.  266. —No  lobule;  no 
fossa  concha ;  shallow  fossa 
scaphoidea;  fusion  of  helix, 
anthelix,  and  antitragus  ;  a  type 
of  Stahl  ear,  No.  3. 


Fig.  267. — Prominent  anthe- 
lix; maldeveloped  helix;  ab- 
sence of  lobule ;  diminution  of 
the  concha;  Wilderniuth  ear, 
No.  1. 


were  apparently  normal  persons.  As  regards  heredity,  it  is  very  com- 
mon for  children  to  inherit  ears  with  the  identical  characteristics  of 
those  of  one  or  the  other  parent,  but,  on  the  other  hand,  it  is  not  uncom- 
mon for  the  ears  of  the  children  to  be  quite  different. 


632 


MENTAL  DISEASES. 


Anomalies  of  the  Limbs. — Paralysis,  atrophy,  retarded  growth, 
club-foot,  and  athetosis  are  conditions  due  to  disease  of  the  brain,  and 
are  observed  in  many  cases  of  paralytic  idiocy.  These  are  not  properly 
stigmata  of  degeneration,  although  they  may  be  such  under  some  cir- 
cumstances, as,  for  instance,  when  club-foot  or  club-hand  has  a  terato- 
logical  origin.  On  the  other  hand,  there  are  anomalies  having  a 
hereditary  character,  which  are  essentially  degenerative  indices.  Among 
these  may  be  mentioned  congenital  luxations,  supernumerary  fingers  or 
toes  (polydactyly),  fusion  of  fingers  or  toes  (syndactyly  or  aschistodactyly), 
excessive  length  of  the  arms  as  compared  with  the  rest  of  the  body  and 
the  lower  limbs,  missing  fingers  or  toes  (ectrodactyly),  missing  limb 
(ectromelus),  fusion  of  the  extremities  (symelus  or  symmelus),  or  ab- 
sence of  parts  of  limbs  so  that  they 
are  excessively  short  (phocomelus). 
There  may  also  be  anomalous  brevity 
of  some  digits  as  compared  Avith  the 
relative  proportions  of  normal  digits. 
Excessive  volume  of  limbs  (megal- 
omelus)  or  digits  (megalodactyly)  or 
excessive  gracility  of  limbs  (oligo- 
melus)  or  of  digits  (oligodactyly)  also 
deserve  mention. 

Anomalies  of  the  Body  in 
General. — Local  malformations  are 
naturally  of  more  importance  than 
general  anomalies  of  the  whole  form, 
but  it  is  necessary  to  study  the  rela- 
tive proportions  of  the  entire  figure 
from  an  anthropometrical  point  of 
view,  and  to  compare  the  results  with 
normal  standards.  Excessive  dim- 
inutiveness  of  figure,  as  well  as  ex- 
cessive or  giant  growth,  are  indications 
of  degeneracy.  So,  too,  are  infantile 
characteristics  in  an  adult,  feminine 
peculiarities  in  males,  and  masculine 
traits  in  females.  In  this  regard,  observations  of  the  relative  pro- 
portions of  the  shoulders  and  pelvis  are  particularly  useful.  The 
occult  form  of  spina  bifida  with  local  hypertrichosis  is  met  with. 
Deviation  of  the  vertebral  column  among  neuropaths  is  mentioned  by 
Fere.  They  may  be  lordoses,  scolioses,  or  kyphoses  in  various  degrees. 
The  coccyx  may  present  peculiarities,  such  as  simulation  of  a  tail. 
Thoracic  asymmetry  or  other  deformity  is  observed  at  times.  Absence 
of  pectoral  muscles,  or  of  muscles  in  various  parts  of  the  body,  has 
significance.  Hernia?  are  evidence  sometimes  of  arrest  of  development 
of  some  part  of  the  abdominal  wall.  Excessive  development  of  mam- 
mary glands  in  males,  or  their  absence  of  reduplication  (polymastia)  in 
either  sex,  constitutes  an  evidence  of  degeneracy. 

Anomalies  of  the  Genital  Organs. — Among  the  genital  anomalies 


Fig.  268. — Phocomelus  right  arm  in  epi- 
leptic girl ;  right  humerus  several  inches 
shorter  than  left ;  arms  otherwise  perfect. 


GENERAL   ETIOLOGY  OF  INSANITY.  633 

in  males  are  cryptorchismus ;  unilateral  or  bilateral  tnicrorchidia ; 
spurious  hermaphroditism;  insufficient  development  of  the  entire  genital 
apparatus  ;  hypospadias  ;  epispadias  ;  defect,  torsion,  or  great  volume  of 
the  prepuce;  median  fissure  of  the  scrotum;  imperforate  meatus. 

In  females  the  labia  may  be  abnormally  large,  simulating  a  scrotum  ; 
sometimes  very  small.  The  clitoris  may  be  exceedingly  large.  The 
labia  minora  may  be  hypertrophied.  Sometimes  there  are  intermediate 
folds  between  the  labia  minora  and  labia  majora.  The  labia  minora 
may  be  pigmented,  particularly  in  brunets  and  when  they  are  hyper- 
trophic. There  may  be  imperforate  vulva,  or  atresia  of  the  vagina,  or 
double  vagina  ;  uterus  bicornis  is  sometimes  met  with. 

Anomalies  of  the  genito-urinary  apparatus  should  always  be  sought 
for,  for,  though  most  frequent  among  idiots,  imbeciles,  epileptics,  and 
the  like,  they  are  by  no  means  rare  in  other  classes  of  degenerates  and 
in  degenerate  families.  In  males,  defect  of  the  testicles  often  coincides 
with  general  excess  of  growth  in 
the  whole  body  or  in  the  lower 
extremities,  such  as  is  often  pro- 
duced by  castration  in  man  and 
lower  animals. 

Anomalies  of  the  Skin. — 
Among  the  anomalies  of  the  skin 
are  to  be  mentioned  adipose 
thickening ;  polysarcia ;  preco- 
cious and  often  abnormal  devel- 
opment of  the  hairy  system  ;  hair 
along  the  spinal  column  ;  rudi- 
mentary tail  ;  premature  gray- 
ness ;  a  glabrous  chin  in  grown 
men  ;  persistent  lanuginous  char- 
acter of  the  hair ;  excessive  growth 

Of  hair  Oil  the   chin  and  breast  in  FiS-  269. -Hypertrichosis  in  a  female  imbecile. 

women ;  complete  or  partial  dis- 
coloration of  the  hair  (albinism,  vitiligo)  ;    local  or  general  hypertri- 
chosis ;  partial  or  complete  absence  or  fetal  state  of  the  nails  ;  melanism 
of  the   skin ;  pigmentary  or  vascular    nevi ;   molluscum ;   ichthyosis  ; 
vitiligo  ;  albinism  ;  pigmented  spots. 

Anomalies  of  Motor  Function. — Delay  in  acquiring  a  knowledge 
of  the  proper  use  of  muscles  for  walking,  eating,  and  the  like  may 
often  be  regarded  as  an  index  of  degeneracy.  Where  ordinary  etio- 
logical factors  may  be  excluded,  tremors,,  tics,  epilepsy,  and  nystagmus 
may  have  a  similar  value.  Even  when  not  congenital,  they  often  indi- 
cate hereditary  instability  of  the  nervous  system. 

Anomalies  of  Sensory  Function. — The  numerous  anomalies  of 
function  in  connection  with  the  eye  have  already  been  mentioned. 
Congenital  deafness  has  also  its  significance.  So,  too,  have  hereditary 
forms  of  migraine  and  neuralgia.  Certain  defects  or  excesses  in  general 
cutaneous  sensibility  have  been  noted  as  frequent  among  degenerates. 
Thus    several    excellent  writers   on   this  subject    have    stated    that   a 


634  MENTAL   DISEASES. 

general  anesthesia  is  not  uncommon,  especially  among  lower  classes 
of  degenerates.      In  some  instances  there  is  hyperesthesia. 

Anomalies  of  Speech. — It  may  be  questionable  as  to  how  far 
stammering  and  stuttering  are  to  be  looked  upon  as  functional  degen- 
erative stigmata,  but  they  are  certainly  found  more  often  in  children 
with  a  neuropathic  inheritance  than  in  children  with  good  heredity. 
Delay  in  the  acquisition  of  language  and  complete  or  partial  defect  of 
speech  have  more  significance. 

Anomalies  of  Genito-urinary  Function. — Sexual  irritability, 
impotence,  sterility,  and  urinary  incontinence  must  be  considered  as 
indices  of  neuropathic  disposition.  Retardation  of  puberty  in  both 
sexes,  but  especially  in  the  male  sex,  is  a  noteworthy  indication. 

Anomalies  of  Instinct  or  Appetite. — It  has  been  pointed  out 
that,  among  all  degenerates,  there  is  a  taste  or  appetite  for  certain  foods 
or  drugs  which  tends  to  favor  their  dissolution  (alcohol,  morphin, 
cocain,  and  the  like).  In  many  cases  of  inebriety  the  uncontrollable 
appetite  is  to  be  looked  upon  as  a  functional  stigma  of  neuropathic 
inheritance.  Gluttony,  merycism,  and  the  like  are  usually  similar  indi- 
cations. 

Miscellaneous. — A  diminished  resistance  against  external  influ- 
ences (such  as  strains  of  various  kind)  and  diseases  is  significant. 
Great  precocity  of  intellectual  development  and  of  certain  aptitudes, 
and  morbid  emotional  conditions,  are  among  suspicious  indications  of  a 
neuropathic  basis. 

The  psychic  stigmata  of  degeneracy  need  only  the  foregoing  enu- 
meration. 


PHYSICAL  AND  MENTAL  STRAIN. 

At  the  beginning  of  this  chapter  I  spoke  of  the  etiology  of  insanity 
as  being  describable  in  two  terms,  heredity  and  strain — heredity,  which 
renders  the  nervous  organization  unstable,  the  strain,  which  causes  the 
unstable  nervous  centers  to  collapse.  Doubtless  there  are  limits  of  en- 
durance in  any  organization,  no  matter  how  strongly  balanced,  if  the 
strain  be  great  enough,  but  the  instances  of  insanity  developing  in  indi- 
viduals with  properly  balanced  and  adjusted  nervous  organizations  are 
rare  indeed.  The  strain  which  breaks  the  unstable  nervous  system  is 
physical  or  moral,  often  both.  What  organism  could  withstand  the 
assaults  upon  its  integrity  of  all  three  of  these  factors — heredity, 
physical  ill-health,  and  cankering  care?  It  is  difficult  to  estimate 
accurately  the  proportion  of  one  cause  as  compared  with  another,  since 
usually  several  are  associated  in  the  same  case ;  but  I  believe  that 
statistics  will  support  me  in  the  statement  that  the  physical  causes  (in 
which  I  include  alcohol,  bodily  diseases  and  disorders,  accident  and  in- 
jury, old  age,  the  puerperal  state,  the  menopause,  and  the  like)  surpass 
the  moral  causes  (grief,  domestic  trouble,  business  worry,  overwork, 
religious  excitement,  love  affairs,  fright,  nervous  shock,  etc.)  as  factors 
in  insanity  by  about  two  to  one — that  is,  twice  as  many  are  made  in- 
sane by  physical  strain  as  by  mental  strain.     It  now  behooves  us  to 


GENERAL  ETIOLOGY  OF  INSANITY.  635 

examine  these  divers  stresses,  and  to  show  how  some  of  them  give  a 
special  color  or  character  to  the  psychosis  developed.  It  i.~  best  to  pre- 
sent them  somewhat  in  the  order  of  their  frequency,  under  two  or  three 
categories,  the  most  common  and  most  important  first,  the  rarest  last. 
The  physical,  physiological,  and  moral  causes,  then,  will  be  considered  in 
the  following  order  : 

Physical  : 

1.  Toxic  (autotoxins,  alcohol,  narcotics,  metallic  poisons,  etc.). 

2.  Bodily  diseases  and  disorders  (syphilis,  acute  and  chronic  disea 

the  nervous  system). 

3.  Trauma  to  the  head. 

4.  Nervous  exhaustion. 

Physiological  : 

1.  Puberty. 

2.  Puerperal  state. 

3.  Menopause. 

4.  Senility. 

Moral : 

1 .  Emotional  strain. 

2.  Imitation. 

Toxic  Influences. — It  is  not  surprising  that  deleterious  agents  in 
the  blood,  which  bathes  every  cell  and  fiber  of  the  nervous  system, 
carrying  thither  the  necessary  nutritional  elements  and  removing 
thence  the  waste  products,  should  readily  overstimulate,  retard, 
pervert,  or  destroy  its  high  functions.  Some  of  these  agents  (like 
alcohol)  also  affect  the  nutrition  of  the  central  nervous  system,  by  in- 
ducing disease  of  the  arteries  and  of  the  stomach,  liver,  and  kidneys. 
Some  of  the  poisons  cause  insanity  by  long-continued  chronic  action 
upon  the  nervous  system,  and  others  by  acute  intoxication. 

Auto-intoxication. — Accumulation  of  deleterious  agents  in  the 
blood  in  such  quantity  as  to  affect  the  nervous  system — e.  g.,  carbonic 
acid  and  the  poison  of  diabetes  and  of  uremia — has  been  long  known  to 
medical  science  ;  but  the  more  mysterious  poisons  produced  by  disease 
in  various  parts  of  the  body,  by  fermenting  or  putrefying  substances  in 
the  alimentary  tract,  and  by  some  of  the  acute  infectious  fevers,  have 
only  of  late  taken  an  important  place  in  the  etiology  of  the  psychoses. 
We  do  not  yet  know  how  frequently  auto-intoxication  from  absorption 
of  intestinal  poisons  determines  insanity,  but  the  facts  thus  far  collected 
point  to  the  origin  of  a  considerable  number  of  cases  from  this  cause. 
These  cases  are  usually  of  depressed  type,  but  sometimes  maniacal. 

Alcohol. — While  the  position  of  autotoxemia  as  a  factor  in  etiology 
is  not  yet  determined,  we  may  say  of  alcohol  that  it  stands  foremost 
(after  heredity)  as  a  single,  independent  cause  (eighteen  to  twenty  per 
cent,  in  males).  Acute  alcoholism  rarely  induces  a  psychosis.  Alcoholic 
insanity  commonly  develops  from  chronic  alcoholism,  from  the  excessive 
use  of  the  poison  for  a  long  period  of  time.  It  is  three  or  four  times 
as  frequent  as  a  factor  in  the  insanity  of  males  as  of  females.  Usually 
it  is  not  difficult  to  discover  the  cause  of  an  alcoholic  insanity, 
but,  should  alcoholic  abuse  be  denied,  an  investigation  of  the  condi- 


€36  MENTAL  DISEASES. 

tion  of  the  viscera  will  often  throw  light  upon  the  subject  (cirrhosis 
of  the  liver,  fatty  heart,  chronic  gastric  catarrh  with  heavily  furred 
tongue,  chronic  nephritis,  and  arteriosclerosis).  Corroborative  evidence 
will  generally  be  afforded,  too,  by  affections  of  the  nervous  system 
(alcoholic  polyneuritis  ;  alcoholic  epilepsy ;  muscular  paresis  here  and 
there  in  the  hands,  face,  or  tongue ;  fibrillary  tremor  of  the  face  and 
tongue,  fine  or  coarse  tremor  of  the  fingers  and  hands ;  paresthesias, 
hyperesthesias,  neuralgias  ;  muscse  volitantes,  tinnitus  aurium,  ambly- 
opia, and  visual  hallucinations).  The  peculiar  psychic  degeneration  of 
alcoholism  is  very  characteristic.  This  consists  of  gradually  weakening 
memory  and  will,  slowness  of  perception  and  judgment,  and  loss  of 
esthetic  and  moral  sense,  with  occasional  states  of  depression  and  ac- 
cesses of  anger.  The  psychoses  which  develop  upon  this  basis  are 
marked  by  two  or  three  features,  which  are  considered  rather  pathogno- 
monic : 

1.  Often  a  peculiar  loss  of  the  sense  of  time  and  place  (a  paramnesia). 

2.  A  tendency  to  illusions  and  hallucinations,  innumerable,  changing, 
mobile,  and  variegated. 

3.  A  tinge  of  weak-mindedness  in  the  psychic  symptoms  presented. 
Hysterical  manifestations  are  not  uncommon  in  alcoholic  insanity. 
Morphin. — Morphin   is,   among  the   alkaloids,   the   most  frequent 

cause  of  insanity.  It  is  a  sad  commentary  on  the  heedlessness  of  some 
medical  men,  but  the  family  physician  is  responsible  in  almost  every 
case  of  development  of  the  morphin  habit  and  its  far-reaching  conse- 
quences. It  should  be  looked  upon  as  a  sin  to  give  a  dose  of  morphin 
for  insomnia  or  for  any  pain  (such  as  neuralgia,  dysmenorrhea,  rheuma- 
tism) which  is  other  than  extremely  severe  and  transient.  The  earliest 
symptom  of  morphinism  is  a  general  sensation  of  disquiet,  manifested 
by  incoherence  of  thought,  difficulty  of  concentration  of  the  mind, 
marked  motor  restlessness,  and  insomnia.  The  dose  is  gradually  in- 
creased, and  may  reach  a  maximum  of  five  or  more  grams. 

The  chief  physical   disorders   induced  by  long-continued   use   of 
morphin  or  opium  are  as  follows  : 

1.  Anorexia  and  constipation  (later,  diarrhea  often). 

2.  Cachectic  anemia. 

3.  Cardiac  weakness  and  intermittence,  and  bradycardia. 

4.  Muscular  weakness  with  tremor. 

5.  Miosis  in  the  early  stages,  mydriasis  later,  with  sluggish  re- 
action of  the  pupils. 

6.  Impotence.     Amenorrhea  in  women. 

7.  The  knee-jerks  are  often  absent. 

8.  Diminished  sensibility  to  touch  and  pain,  and  concentric  limi- 
tation of  the  visual  fields. 

9    Headaches  and  localized  shooting  pains,  neuralgias,  and  pares- 
thesias. 

10.  Sensation  of  feeling  cold. 

The  psychic  symptoms  may  be  summarized  briefly,  thus  : 
1.  Simple  elementary  illusions  and  hallucinations,  muscse  volitantes, 
tinnitus  aurium. 


GENERAL   ETIOLOGY  OF  INSANITY.  637 

2.  Loss  of  will  and  esthetic  sense,  irritability  ;  moral  perversion,  a.- 
in  alcoholic  psychic  degeneration,  but  with  little  failure  of  memory. 

3.  Diminished  attention,  incoherence  of  ideas,  and  easily  fatigued 
intellectual  powers. 

A  well-developed  psychosis  is  usually  the  result  of  abstinence  from 
morphin,  and  not  of  the  chronic  misuse  of  it.  It  varies  in  degree  up 
to  a  type  approaching  acute  mania. 

Cocain. — Of  recent  years  there  have  been  numerous  instances  of 
cocain  insanity,  and  they  are  doubtless  growing  more  frequent.  While 
with  morphin  it  is  the  abstinence  that  is  prone  to  induce  a  psychosis, 
with  cocain,  on  the  contrary,  it  is  the  prolonged  use  of  the  drug  that 
develops  the  insanity,  while  abstinence  gives  rise  to  few  noteworthy 
symptoms.  The  misuse  of  cocain  leads  to  the  evolution  of  an  acute 
hallucinatory  paranoia. 

Hashish  (Cannabis  Indica). — We  never  see  insanity  from  this 
cause  in  America,  but  in  Egypt  and  India  it  is  extremely  common.  In 
visits  paid  by  the  writer  to  the  Cairo  Insane  Asylum  in  the  winter  of 
1891-92, 1  he  observed  64  cases  of  the  248  patients  in  the  institution 
in  which  the  insanity  was  due  to  the  inhalation  of  hashish  by  smoking. 
The  symptoms  produced  are  indigestion,  diarrhea,  increased  appetite, 
dilatation  of  the  pupils,  drooping  eyelids,  anemia,  general  debility,  and 
delirium.  The  earliest  mental  symptom  is  marked  and  increasing 
timidity,  sometimes  amounting  to  folie  du  doute,  or  an  agoraphobia. 

Atropin  ;  Hyoscyamin  ;  Hyoscin. — These  isomeric  alkaloids  have 
much  the  same  physiological  eifects  (mydriasis,  paralysis  of  accommo- 
dation, dryness  of  the  throat,  depressed  heart's  action,  dreadful  illusions 
and  hallucinations,  etc.),  but  instances  are  not  common  of  their  giving 
rise  to  psychoses.  However,  it  is  probable  that  the  employment  of  one 
of  these  as  a  secret  cure  for  drunkenness  has  been  the  cause  of  serious 
insanity  in  a  considerable  number  of  cases  that  have  found  their  way 
from  sanatoriums  to  asylums.2 

Metallic  Poisons. — Lead  and  mercury  at  times  induce  insanity,  the 
former  much  more  frequently  than  the  latter.  The  intoxication  is 
chronic,  but  the  psychosis  developed  may  be  either  acute  or  chronic. 
Both  of  these  poisons  produce  similar  psychic  symptoms,  such  as  ver- 
tigo, sleeplessness,  rudimentary  or  marked  hallucinations,  confusion  and 
incoherence,  anxious  depression,  and  often  persecutory  delusions.  In 
severe  cases  there  is  dementia.  In  lead  cases  there  are  usually  to  be 
observed  the  concomitant  physical  symptoms,  such  as  anemia,  colic, 
blue  line  on  the  gums,  tremor,  arthralgia,  palsies,  and  convulsions.  In 
mercury  cases  we  note  stomatitis,  tremor,  and  gastro-intestinal  catarrh. 
Hysterical  symptoms  are  not  infrequently  superadded  upon  the  lead 
and  mercury  psychoses. 

Various  Poisons. — There  are  many  other  poisons  which,  in  rare 
instances,  produce  insanity.  Among  these  may  be  mentioned  coal-gas, 
carbonic  oxid,    stramonium,  henbane,  hemlock,   bisulphid    of   carbon, 

1  "The  Insane  in  Egypt,"  "N.  Y.   Med.  Record,"  May  21,  1892. 

2  Dr.  B.  D.  Evans,  Superintendent  of  the  Morris  Plains  Asylum,  N.  J.,  has  col- 
lected a  number  of  such  cases. 


638  MENTAL   DISEASES. 

etc.  The  writer  described  some  years  ago  three  cases  of  bisulphid  of 
carbon  insanity  which  ran  their  course  under  the  type  of  acute  mania 
going  on  to  recovery,  studied  by  him  at  the  Hudson  River  State 
Hospital  for  the  Insane.1  All  three  were  workers  in  a  rubber 
factory. 

Bodily  Diseases  and  Disorders. — -Syphilis. — Syphilis  is  one  of 
the  most  important  of  the  physical  causes  of  insanity.  It  acts  upon 
the  brain  indirectly  through  wide-spread,  severe  disturbance  of  general 
nutrition  and  through  arteriosclerosis,  and  directly  by  the  production 
of  diffuse  changes  in  the  tissues  of  the  central  nervous  system,  or  of 
circumscribed  meningeal  deposits  or  intracerebral  gumma ta.  The  degen- 
eration of  cells  and  fibers,  the  gliosis  and  the  arteriosclerosis,  are  possibly 
due  to  toxins  created  by  specific  micro-organisms,  and  not  to  the  direct 
influence  of  the  germs  themselves,  which  may  explain  why  syphilitic 
psychoses  are  ordinarily  late  manifestations  of  syphilis.  General 
paralysis  and  cerebral  syphilis  are  the  chief  phases  in  which  the  psy- 
chosis is  presented.  It  is  often  difficult  to  obtain  a  history  of  syphilis 
in  a  patient,  so  that  the  statistics  as  to  the  frequency  of  syphilis  as  a 
cause  of  general  paresis,  for  instance,  are  generally  faulty.  Where  the 
history  is  uncertain,  a  careful  examination  may  indicate  the  existence 
of  syphilis  (hereditary  syphilis  in  the  children,  leukoderma,  cicatrices, 
swelling  of  the  lymph-glands,  periosteal  deposits  and  tophi,  perforation 
of  the  palate,  nasal  symptoms,  etc.). 

Hereditary  syphilis  plays  a  part  in  the  etiology  of  the  psychoses  of 
early  life, — for  example,  imbecility  and  idiocy, — though  probably  not 
so  great  a  part  as  is  frequently  asserted,  for,  in  a  considerable  experience 
with  such  conditions  at  the  Randall's  Island  Asylum  for  Idiots,  I  have 
seen  but  little  hereditary  syphilis. 

Acute  Infectious  Diseases. — Typhoid  fever,  malaria,  pneumonia, 
influenza,  and  acute  articular  rheumatism  head  the  list  of  acute  fevers 
which  sometimes  superinduce  insanity.  Disturbances  of  nutrition, 
high  fever,  and  toxic  changes  in  the  blood  are  responsible  for  the 
symptoms  developed.  Perhaps  the  toxin-producing  bacteria  are  the 
chief  agents,  acting  by  direct  influence  upon  the  cortical  cells  and  fibers. 
If  this  be  true,  these  cases  were  better  classed  under  the  head  of  Toxic 
Influences.  At  the  height  of  a  fever  we  have  a  febrile  delirium,  char- 
acterized by  hallucinatory  incoherence  ;  but,  later  on,  when  the  fever  has 
diminished  and  the  organism  is  weakened  by  disease,  such  manifestation 
is  termed  "  inanition  delirium."  From  either  the  febrile  or  inanition 
delirium  a  psychosis  may  develop,  usually  assuming  the  type  of  a  hallu- 
cinatory paranoia  with  self-depreciatory  or  persecutory  delusions,  in 
some  cases  with  a  tendency  to  agitation,  in  others  with  inclination  to  a 
stuporous  condition.  Mania  and  melancholia  are  rare,  stupidity  with  a 
proclivity  to  terminal  dementia  more  common.  Malarial  psychoses 
sometimes  exhibit  a  certain  periodicity  corresponding  to  the  intermittent 
nature  of  the  cause.  Heredity,  alcoholic  degeneration,  etc.,  also  play 
a  considerable  part  in  the  etiology  of  this  form  of  toxic  mental  disorder. 

1  "Boston  Med.  and  Surg.  Jour.,"  Oct.,  1892. 


GENERAL   ETIOLOGY  OF  INSANITY.  639 

Tuberculosis. — The  disturbances  of  nutrition  in  tuberculosis,  ae 
well  as  the  mental  depression  sometimes  associated   with  the  disease, 

occasionally  lead  to  the  development,  out  of*  an  exhaustion  or  inanition 
delirium,  of  a  true  psychosis — a  melancholia  or  a  hallucinatory  excite- 
ment. It  may  be  said,  however,  that  the  relation  of  tuberculosis  To 
insanity  is  much  more  frequently  that  of  sequel  than  of  prodrome,  for 
many  cases  of  melancholia  and  stuporous  forms  of  insanity  die  of  this 
disease  owing  to  shallow  respiratory  functions  and  insufficient  nutrition. 

Carcinoma. — The  progressive  cachexia  induced  by  malignant  dis- 
ease, as  well  as  the  direct  effects  of  cerebral  metastases,  sometimes  lead 
to  psychopathic  conditions  resembling  those  of  tuberculosis. 

Heart  Disease  and  Atheromatous  Arteries. — Cardiac  disease  is 
frequently  found  among  the  insane,  but  its  precise  relation  to  the 
psychoses  is  obscure.  Doubtless,  in  so  far  as  it  disturbs  the  circulation 
and  interferes  with  cerebral  nutrition,  it  predisposes  to  mental  instability. 
On  the  other  hand,  disease  of  the  arteries  (senile,  nephritic,  syphilitic, 
alcoholic,  cachectic),  is  a  much  more  effective  disturber  of  nutrition, 
and  at  the  same  time  gives  rise  to  serious  focal  lesions,  such  as  miliary 
aneurysms,  thrombosis,  and  hemorrhage,  which  may  be  etiologically 
associated  with  various  psychopathies. 

Nephritis. — The  nephritic  psychoses  assume  usually  the  type  of  a 
hallucinatory  paranoia,  and  therein  resemble  other  toxic  insanities.  It 
is  probable  that  toxic  changes  in  the  blood  are  here  of  more  importance 
than  the  changes  in  the  vascular  walls,  though  these,  too,  have  their 
significance. 

Gastro-intestinal  Disorders. — These  sometimes  induce  hypochon- 
driacal melancholia,  and  predispose  to  psychoses  of  various  kinds  by 
disturbing  nutrition  ;  but  their  frequent  relation  to  insanity  is  generally 
a  consequence  rather  than  a  cause. 

Diseases  of  the  Genital  Organs. — There  are  serious  disorders  of 
the  female  genital  organs  which  occasionally  play  a  role  in  the  causa- 
tion of  insanity,  but  their  importance  as  factors  has  been  grossly 
exaggerated,  and  much  harm  and  little  good  have  followed  operative 
interference  for  the  relief  of  the  insanity.  Probably  the  cessation  of 
menstruation  (usual  in  acute  insanities)  has  been  misinterpreted  as 
significant  of  genital  disease,  and  thus  given  rise  to  a  grave  error. 

I  would  not  be  understood  as  decrying  operative  or  other  treatment 
altogether,  if  such  be  indicated  ;  but  let  no  one  be  deceived  into  expect- 
ing benefit  from  the  procedures,  except  in  rare  instances. 

Having  briefly  examined  most  of  the  general  physical  disorders 
which  are  concerned  in  the  causation  of  insanity,  we  will  now  turn  our 
attention  to  certain  functional  diseases  of  the  nervous  system  which,  by 
reason  of  their  localization  in  the  cerebral  cortex,  are  prone  to  assume 
a  very  important  part  in  psychopathology.  These  are  epilepsy,  hysteria, 
and  chorea. 

Epilepsy. — Epilepsy  is  almost  as  common  a  disease  as  insanity 
itself.  Asylum  physicians,  whose  experience  with  epilepsy  is  limited  to 
cases  associated  with  mental  disorder,  tend  to  overestimate  the  frequency 
of  insanity  among  epileptics.     Thus,  it  is  often  stated  by  them  that  psychic 


640  MENTAL  DISEASES. 

degeneration  is  manifested  in  sixty  to  eighty  per  cent,  of  all  epileptics. 
But  the  fact  is  that  probably  not  more  than  ten  to  fifteen  per  cent,  of 
epileptics  develop  insanity ;  at  the  same  time  the  proportion  is  so  large 
as  to  show  a  close  relation  between  this  functional  cortical  malady  and 
mental  disorders.  When  progressive  epileptic  degeneration  occurs,  it 
manifests  itself  by  the  following  symptoms  : 

1.  Slowness  of  ideation  and  articulation. 

2.  Abnormal  irritability  of  temper. 

3.  Hypochondriacal  depression. 

4.  Paranoid  outbreaks  of  various  kinds. 

5.  Dementia. 

Hysteria. — Hysteria  is  also  a  functional  neurosis  of  the  cortex, 
often  closely  associated  with  divers  psychoses.  There  is  a  species  of 
hysterical  psychic  degeneration,  and  the  neurosis  frequently  gives  a 
special  color  to  different  forms  of  insanity.  The  symptoms  noted 
(aside  from  the  peculiar  sensory  and  motor  manifestations  familiar  to  us 
in  simple  hysteria)  on  the  mental  side  are  as  follows  : 

1.  Lack  of  logical  coherence  and  sequence  of  thought,  but  with 
perfect  intelligence.  Defects  of  memory,  with  rudimentary  persecutory 
and  erotic  delusions,  are  encountered  frequently. 

2.  Extreme  uncontrolled  and  morbidly  changeable  emotions.  Pro- 
found egotism. 

3.  Frequent  illusions  ;  occasional  hallucinations. 

4.  Conduct  and  speech  are  based  upon  emotional  impulsiveness,  un- 
controlled by  ethical  considerations  of  any  kind. 

Organic  Nervous  Diseases. — The  psychic  disorders  induced  by 
organic  processes  in  the  brain,  such  as  meningitis,  tumor,  softening, 
hemorrhage,  and  the  like,  are  characterized  either  by  symptoms  of  re- 
tardation of  functions  or  by  symptoms  of  irritation,  and  are  due  either 
to  pressure  or  to  the  indirect  influence  of  the  lesion  upon  the  circula- 
tion or  nerve-centers  and  tracts.  Emotional  irritability,  hallucinations 
of  the  various  senses,  defects  of  intelligence  reaching  to  imbecility  or 
idiocy,  stuporous  conditions — these  are  common  mental  manifestations 
of  such  processes.  Since  single  localized  lesions  are  apt  to  produce  slight 
mental  changes,  any  marked  intellectual  defect  or  multiform  psychic 
symptoms  may  be  looked  upon  as  suggestive  of  wide-spread,  perhaps 
multiple,  lesions,  such  as  multiple  sclerosis,  multiple  tumors,  syphilis,, 
etc.  Sometimes  true  insanities  develop  in  these  cases,  particularly 
when  there  is  hereditary  instability  of  nervous  organization. 

Trauma  to  the  Head. — A  blow  upon  the  head  is  one  of  the  most 
direct  of  stresses  to  which  the  brain  can  be  subjected.  It  is  not  so 
much  the  local  effect  of  the  injury  (which,  indeed,  would  not  present 
psychic  symptoms  differing  materially  from  those  of  any  other  local 
lesion  of  the  brain  such  as  have  just  been  considered),  but  the  general 
effect  of  a  commotio  cerebri  that  we  are  called  upon  to  consider.  The 
syndrome  of  mental  disorders  induced  by  such  cause  has  been  well 
termed  by  the  Germans  "  commotion  insanity."  The  effect  of  a  violent 
blow,  jar,  or  jolt  to  the  head  must  have  some  influence  upon  the  mole- 
cules of  the  brain  as  well  as  upon  the  encephalon  as  a  mass,  must  dis- 


GENERAL  ETIOLOGY  OF  INS  A  MTV.  641 

place  and  disarrange  delicate  microscopic  structures,  such  ae  the  cells 
and  fibers.  If  the  blow  be  insufficient  to  produce  complete  loss  of  con- 
sciousness, there  will  be  a  dazed,  bewildered  condition,  and  the  patienl 
will  struggle  or  grope  about  in  a  confused  way.  There  may  be  a  Loss 
of  memory,  more  or  less  extensive,  as  a  result.  Naturally,  the  newest 
organizations  of  tissues,  being  the  most  fragile,  will  be  the  most  easily 
disarranged;  hence,  with  amnesic  defects,  it  will  be  the  most  recent 
acquisitions,  or  such  as  cluster  about  the  time  of  the  injury,  which  will 
suffer  most.  The  patient  will  experience  strange  sensations  in  his 
head.  The  head  may  feel  as  if  it  were  going  around.  Objects  seem 
to  move.  There  is  a  feeling  of  being  intoxicated  or  of  dizziness.  A 
general  hyperesthesia  and  hyperalgesia  are  not  uncommon,  while  a 
hypalgesia  is  occasionally  observed.  Among  psychic  symptoms  hallu- 
cinations and  painful  effects  are  prominent,  generally  of  a  terrifying 
nature.  Associations  may  be  so  interfered  with  as  to  induce  difficult 
ideation,  mental  confusion,  and  a  genuine  primary  incoherence.  The 
motor  expressions  are  often  characteristic,  consisting  of  catatonic  con- 
ditions, impulsive  acts  of  violence,  and  aimless  wandering  about.  In 
some  cases  no  particular  results  of  the  trauma  are  noted  until  the  lapse 
of  a  few  hours  or  days,  when  suddenly  the  traumatic  psychosis  de- 
velops. After  the  psychosis  has  run  an  acute  course,  a  condition  of 
chronic  insanity  or  of  a  secondary  dementia  may  follow.  Such  a 
secondary  dementia  may  simulate  very  closely  general  paresis,  particu- 
larly if  it  be  progressive.  It  can  not  be  said  that  there  are  any  well- 
authenticated  cases  of  true  general  paralysis  dependent  upon  trauma- 
tism. 

There  are  not  infrequently  instances  of  the  creation,  by  trauma  to 
the  head  which  has  induced  no  direct  evil  consequences,  of  an  unstable 
nervous  system,  of  a  predisposition  upon  which  other  etiological  factors 
may  operate  later  in  life. 

Insolation  probably  acts  upon  the  brain  in  a  manner  similar  to  trau- 
matism. 

Nervous  Exhaustion. — Stresses  of  various  kinds,  mental  or  phys- 
ical, especially  in  conjunction  with  the  impairment  of  the  nutrition  of 
the  central  nervous  system,  induce  an  exhaustion  upon  the  basis  of 
which  a  psychosis  may  develop.  The  mental  strain  may  be  from  over- 
work, overstudy,  insomnia,  and  the  like  ;  the  physical  from  masturba- 
tion, sexual  excess,  hardships.  The  nutritive  impairment  is  the  result 
of  some  blood-change  or  deficiency,  such  as  constitutional  anemia,  a 
cachectic  state,  etc.  The  physical  symptoms  of  such  exhaustion  are  : 
slowing  of  the  thought  processes,  difficulty  of  recollection,  want  of 
ability  to  concentrate  the  attention,  rapid  fatigue  on  mental  exertion, 
emotional  irritability  with  an  undertone  of  depression,  leading  often  to 
fully  developed  insanities,  which  are  designated  as  asthenic  psychoses. 
The  common  features  of  such  psychoses  are  retardation  and  incoherence 
of  the  mental  processes,  manifested  even  in  the  quality  of  the  halluci- 
nations and  delusions.  But  almost  any  form  of  insanity  may  be  evolved 
from  this  asthenic  state  of  the  nervous  system,  such  as  mania,  neuras- 
thenia, stuporous  states,  and  various  types  of  paranoia. 
41 


642  MENTAL  DISEASES. 

As  Ziehen  points  out,  it  is  also  interesting  to  observe  how  any  ex- 
hausting psychosis  may  in  itself  induce  this  asthenic  condition  with  the 
characteristic  features  of  an  asthenic  psychosis,  as  a  result  of  which  we 
have  a  secondary  type  of  mental  disorder  developed  upon  the  basis  of 
the  original  insanity. 

Physiological  Factors. — Puberty,  the  puerperal  state,  the  climac- 
teric, and  senility  are  indirect  strains  to  which  the  organism  is  subject, 
by  reason  of  the  more  or  less  profound  physiological  commotions  they 
arouse  in  the  nervous  system — commotions  which  may  well  disturb  the 
normal  adjustment  and  equipoise  of  the  thousands  of  delicate  processes 
going  on  in  the  brain,  and  thus  enormously  increase  its  vulnerability  to 
the  direct  factors  which  beget  insanity. 

The  curve  of  psychic  morbidity  reaches  its  highest  points,  corre- 
sponding to  maximal  aggregations  of  etiological  factors  in  both  sexes,  at 
puberty,  middle  age,  puerperal  periods,  the  climacteric,  and  senility. 

Puberty. — From  the  thirteenth  to  the  twentieth  year  there  are  re- 
markable changes,  physical  and  mental,  in  the  growing  individual. 
These  are  more  noteworthy  in  the  female  than  in  the  male  sex,  for  the 
time  is  shorter  for  the  change  from  girlhood  to  womanhood  than  from 
boyhood  to  manhood.  The  evolution  of  the  sexual  characters  and  the 
development  of  the  powers  of  reproduction  induce  a  stream  of  innu- 
merable new  stimuli  from  the  genital  organs  to  the  brain,  accompanied 
by  wholly  new  organic  sensations,  new  associations,  and  new  and  power- 
ful emotions.  The  evolution  is  rapid,  and,  as  is  the  case  with  all  rapid 
development,  more  or  less  unstable. 

The  boy  grows  fast  in  body,  takes  on  the  aspect  of  manhood,  with 
a  stronger  and  more  rugged  frame,  a  changing  voice,  a  budding  beard. 
His  mind  is  filled  with  new  sensations,  emotional,  sentimental,  amatory, 
and  with  changing,  fantastic,  illusory  dreams  and  imaginings.  Even  in 
the  normal  youth  this  nascent  state,  this  struggle  of  the  emotions, 
thoughts,  instincts,  impulses  for  new  associations  and  new  combinations, 
may  be  greatly  aggravated  in  many  cases  by  masturbation,  in  others  by 
nutritive  disorders.  If  this  be  so  with  the  normal  individual,  how 
much  greater  must  be  the  stress  of  puberty  to  the  individual  with  a 
constitution  vitiated  by  hereditary  taint ! 

The  girl  leaps  more  quickly  into  her  place  in  life.  The  physical 
changes  are  more  rapid  in  her,  and  at  the  same  time  more  varied  and 
noteworthy.  It  is  a  time  of  tumultuous  activity  of  mind  and  body  in 
an  organism  which  has  not  the  numerous  outlets  for  surplus  energy 
possessed  by  the  other  sex. 

The  psychoses  of  puberty  are  various  in  their  expression.  They 
may  manifest  themselves  as  a  mania,  a  melancholia,  a  paranoia,  or  as  an 
insanity  with  peculiar  color,  to  which  the  name  hebephrenic  modification 
has  been  given  ;  so  that  we  speak  of  a  hebephrenic  mania,  a  hebephrenic 
melancholia,  etc. 

By  the  designation  hebephrenic  is  understood  the  following  syn- 
drome :  Extraordinarily  rapid  and  paradoxical  changes  (depressed  ideas 
in  the  midst  of  boisterous  gaiety,  jocularity  in  the  deepest  depression), 
with    paradoxical    facial    expression    and    paramimia ;    exalted    motor 


GENERAL  ETIOLOGY  OF  INSANITY.  643 

activity  (laughing,  dancing,  grimacing,  exhorting  after  the  manner  of 
an  orator,  often  with  incomprehensible  words  and  sentences)  ;  conduct 

and  action  without  apparent  object,  but  often  with  the  semblance  of 
desiring  to  attract  attention. 

Puerperal  State. — Pregnancy,  parturition,  and  lactation  diminish 
the  vitality  of  woman,  debilitate  and  weaken  her  entire  organism, 
induce  a  species  of  physiological  commotion  in  her  nervous  system,  and, 
in  short,  bring  to  bear  a  strain  upon  her  which  is,  even  under  normal 
conditions,  attended  by  emotional  irritability,  depression,  morbid  yearn- 
ings, etc.  It  is  not  strange,  therefore,  that  the  puerperal  period  in 
women  with  unstable  nervous  systems  should  often  be  an  exciting  factor 
in  the  development  of  psychoses  of  various  kinds.  In  about  ten  per 
cent,  of  insane  women  the  insanity  has  its  origin  at  the  epoch  of  repro- 
duction. The  majority  of  these  cases  are  parturitional  (seven  and  a 
half  per  cent.),  while  about  a  fourth  are  lactational  and  a  tenth  preg- 
nancy eases.  It  is  perhaps  true  that  there  are  many  cases  of  partu- 
ritional psychoses  in  which  the  insanity  is  not  so  much  due  to  the  stress 
of  labor  as  to  possible  auto-intoxications  from  poisonous  substances 
absorbed  during  the  catabolic  changes  incident  to  subinvolution  of  the 
enlarged  uterus.  As  important  factors,  too,  we  must  include  loss  of 
blood,  parametritis,  sepsis,  mastitis,  etc. 

There  are  divers  forms  of  insanity  consequent  to  the  puerperal  state, 
such  as  acute  hallucinatory  paranoia,  melancholia,  stuporous  insanity, 
mania,  and  neurasthenic  insanity. 

Menopause. — The  climacteric,  between  the  ages  of  forty  and  fifty, 
is  another  epoch  of  change  in  woman,  a  period  of  involution  in  its  way 
analogous  to  the  evolution  at  the  age  of  puberty.  There  is  a  physio- 
logical commotion  in  the  nervous  system  at  the  time  of  the  cessation 
of  ovulation  and  menstruation,  a  disequilibration  associated,  even  in 
normal  individuals,  with  numerous  neurotic  manifestations,  and ,  in  such 
as  have  unstable  organizations,  attended  with  peril  to  the  mental  in- 
tegrity. Melancholia,  simple  and  hallucinatory  paranoia  of  chronic 
character,  and  circular  insanity  are  the  forms  of  psychosis  incident  to 
the  menopause.  About  four  per  cent,  of  the  cases  of  insanity  in  women 
are  due  to  the  climacteric. 

Senility. — The  involution  of  all  the  tissues  of  the  body  characteristic 
of  especially  the  seventh  decad  of  life  forms  also  a  frequent  basis  for 
insanity  which  depends,  in  the  main,  upon  the  loss  of  functional  activity 
in  the  cerebral  cortex.  Such  loss  is  notable  even  in  normal  individuals. 
The  latest  acquisitions  of  the  mind  are  the  least  stable ;  hence  the  con- 
spicuous loss  of  memory  for  events  of  recent  occurrence  and  the  ten- 
dency to  live  in  the  past.  The  scope  of  interests,  sympathies,  and  ideas 
narrows  itself  down  to  the  individual's  immediate  physical  comfort  and 
needs.  While  the  physiological  involution  of  senility  belongs  to  the 
seventh  decad,  in  many  instances  it  begins  long  before  this,  owing  to 
general  debility,  endarteritis,  etc.  Marked  changes  in  the  brain  of 
such  nature  must,  therefore,  often  superinduce  veritable  psychoses  in 
individuals  predisposed  to  mental  disorder  by  heredity  or  by  antecedent 
physical  or  psychic  stresses. 


644  MENTAL  DISEASES. 

Senile  insanities  manifest  themselves  in  many  forms, — melancholia,, 
mania,  incoherent  paranoia,  hallucinatory  paranoia,  dementia, — but,  of 
course,  modified  from  the  common  types  by  the  weakening  of  the  cor- 
tical functions  previously  described.  Vertiginous  seizures,  slight  pare- 
ses,  dreadful  hallucinations,  and  primary  anxious  conditions  are  often 
observed  in  all  of  these  forms. 

The  hallucinations  appear  in  senile  forms  in  psychoses  which  ordi- 
narily run  their  course  without  them,  and  the  anxious  states  in  ordinarily 
non-affective  insanities. 

Moral  Causes. — About  twenty-four  per  cent,  of  all  cases  of  insanity 
are  ascribed  to  moral  causes,  among  which  are  classed  domestic  troubles, 
grief  over  death  of  friends,  business  worries,  anger,  religious  excitement, 
love  affairs,  fright,  and  nervous  shock.  The  percentage  is  greater  in 
women  than  in  men.  It  is  doubtful  if  any  emotion  alone  can  overcome 
the  stability  of  the  normal  nervous  system  ;  hence  it  is  in  the  fragile, 
nervous  constitutions  of  individuals  tainted  by  heredity  that  extreme 
emotions  are  wont  to  exert  their  malign  influence. 

The  uncertain  equilibrium  of  the  highest  nerve-centers  in  these  cases 
is  all  too  readily  overcome  by  the  tumultuous  wave  of  an  intense 
emotional  impression.  Possibly,  the  results  depend  upon  disturbance 
of  the  vascular  innervation.  Ordinarily,  the  greater  and  more  sudden 
the  emotion,  the  greater  the  liability  of  the  badly  poised  brain  to  suc- 
cumb ;  but,  like  the  drops  that  wear  away  the  stone,  an  emotion  of  less 
intensity  may,  by  long  continuance,  produce  equally  disastrous  conse- 
quences. Some  acute  psychoses  may  be  suddenly  developed  by  fright, 
or  a  transitory  emotional  insanity  for  a  few  hours  or  for  a  few  days  in 
duration.  Among  the  symptoms  are  mutism,  or  incoherence,  confusion, 
isolated  hallucinations,  delusions,  with  impulses  to  violence  and  aimless 
wandering,  followed  later  by  complete,  or  nearly  complete,  amnesia. 

The  more  slowly  working  affects,  like  sorrow  and  worry,  often  aid  in 
the  evolution  of  melancholia,  paralytic  dementia,  or  acute  or  chronic 
paranoia. 

Imitation. — The  so-called  psychic  infection  never  influences  normal 
individuals  who  are  brought  into  contact  with  the  insane.  Physicians, 
attendants,  and  others  who  have  to  do  with  the  insane  are  never 
affected,  except  when  morbid  heredity  and  mental  and  physical  over- 
work combine  to  prepare  the  soil  for  the  development  of  a  psychosis. 
The  writer  recalls  but  one  instance  of  an  attendant  being  mentally 
unbalanced  during  her  service.  She  was  neurotic  by  constitution  and 
cut  her  throat  a  few  days  after  one  of  her  patients  had  committed  sui- 
cide in  the  same  manner.  But  there  are  not  infrequent  instances  of 
communicated  insanity  among  members  of  a  family. 

The  simultaneous  development  of  insanity  in  two  or  more  persons 
associated  together,  or  the  imposition  of  delusions  gradually  arising  in 
the  mind  of  one  upon  the  impressionable  intellect  of  a  second,  third,  or 
of  many  persons,  has  been  described  under  the  names  Folie  a  Deux,  Folie 
Simultane'e,  Reciprocal  Insanity,  Folie  Impos&e,  etc.  There  are  several 
factors  which  govern  the  evolution  of  such  insanities.  In  both  forms  a 
degenerative  soil  is  usually  required  for  the  proper  germination  and 


GENERAL   ETIOLOGY  OF  INSANITY.  645 

growth  of  morbid  ideas.  In  the  simultaneous  variety  there  must  be,  in 
addition  to  predisposition,  that  similarity  of  intellectual  substrata  which 
wc  find  particularly  in  persons  who  are  blood-relations  or  who  are  inti- 
mately joined  together  by  mutual  like  and  dislike  ;  hence  it  is  that 
brothers  or  sisters  most  frequently  manifest  simultaneous  insanity. 
Take  two  healthy  children  of  one  family  and  bring  them  up  far  apart, 
yet  there  will  be  innumerable  physical  resemblance-;  between  them,  and 
many  peculiarities  in  their  character  and  conduct  which  prove  them  to 
be  consanguineous ;  if  a  hereditary  instability  of  nerve-cells  had  been 
implanted  in  them,  there  would  be  a  tendency  to  a  similar  form  of  dis- 
solution, even  if  they  remained  apart.  How  much  greater  would  this 
be  in  two  persons  so  intimately  associated  as  sisters,  for  instance.  In 
children  the  study  of  unconscious  imitation  is  one  of  gnat  interest. 
Who  has  not  observed  the  identity  of  intonation  of  phrases,  of  gesture, 
of  laughter,  of  many  facial  expressions,  of  certain  habits,  in  children 
either  related  or  brought  up  together  ?  Such  unconscious  imitation,  as 
is  well  known,  may  lead  in  children  to  the  contraction  of  certain  nervous 
and  even  mental  diseases.  The  contagious  quality  of  emotions  is  well 
established.  An  explosion  of  laughter  will  call  up  smiles  on  even 
melancholy  faces  in  a  crowd.  A  pathetic  scene  on  a  stage  will  bring 
tears  and  depress  the  oral  angles  in  a  large  audience.  The  unconscious 
imitation  of  gestures,  such  as  bowing,  often  seen  in  adults,  is  in  a  milder 
degree  such  mimicry  of  motion  as  is  observed  in  dancing  mania. 

Another  element  in  the  imposition  of  insanity  by  one  upon  another 
is  the  quality  of  the  morbid  mind-product.  If  a  delusion,  it  must  have 
an  air  of  probability  to  the  person  receiving  it,  and  must  be  gradually 
developed  and  imposed.  It  is  because  suspicion  is  inherent  in  the 
nature  of  most  persons,  because  suspicion  can  wear  so  much  probability 
of  truth,  that  persecutory  delusions  are  by  far  the  most  frequently 
adopted  by  others.  Credulity  is  an  important  factor  in  the  imposition 
of  insane  delusions  upon  others.  It  was  the  ready  credulity  of  large 
numbers  of  persons,  especially  as  regards  religious  subjects,  that  in 
the  past  led  hundreds  of  thousands  of  people  to  adopt  with  faith  the 
delusions  of  paranoiacs  like  John  of  Leyden,  John  Thorn  of  Canterbury, 
Joan  of  Arc,  Richard  Brothers,  Joanna  Southcott,  John  Brown,  and 
many  others,  and  actually  to  sacrifice  their  lives  upon  the  altar  of  their 
beliefs.  Though  these  delusions  emanate  from  an  insane  person,  their 
acceptance  by  others  does  not,  of  course,  necessarily  imply  insanity  in 
the  latter,  for  delusions  of  this  character  have  their  support  in  the 
superstitions  of  many  and  in  ignorance  concerning  supernatural  matters. 
A  persecutory  delusion  might  be  imposed  by  an  insane  person  upon  an 
intimate  associate,  and  yet  the  latter  need  not,  of  necessity,  be  insane  ; 
but  when  the  exposed  individual  adopts  the  delusions,  regulates  his 
conduct  upon  them,  allows  them  to  become  rooted  in  his  mind,  even 
begins  to  share  the  hallucinations  of  his  friend,  there  is,  of  course,  actual 
aberration  of  mind  present.  Several  cases  of  folie  a  deux  have  come 
under  my  observation.  One  case  was  that  of  two  sisters,  aged  about 
fifty  to  fifty-five,  Irish,  washerwomen,  who,  living  alone  in  a  tumble- 
down shanty,  were  often  tormented  by  boys  throwing  stones  at  the 


646  MENTAL  DISEASES. 

house  at  night,  and  otherwise  teasing  them.  They  finally  developed 
persecutory  delusions  with  hallucinations,  and  both  were  very  much 
alike.  They  became  so  violent  in  their  demonstrations  that  ere  long 
both  were  taken  to  the  asylum,  where  I  took  charge  of  them.  They 
were  separated,  the  result  being  that  one  became  rapidly  demented  and 
the  other  became  a  quiet  worker,  with  fixed  persecutory  ideas  and 
auditory  hallucinations. 

Another  pair  of  sisters,  colored,  between  forty  and  fifty  years  of 
age,  were  similarly  affected.  For  ten  years  one  sister  had  been  a  para- 
noiac, with  delusions  of  persecution  by  means  of  electricity,  which 
was  at  all  times,  night  and  day,  hurled  through  her  body  by  a  vast 
organization  of  conspirators.  She  had  hallucinations  of  hearing.  The 
sisters  had  not  lived  together  until  within  six  months  of  my  seeing  them, 
the  sane  sister  having  recently  become  a  widow.  The  sane  sister  grad- 
ually adopted  the  delusions  of  the  insane  one,  and  probably  the  hallu- 
cinations. She  believed  her  sister  to  be  persecuted  by  an  organized  band 
of  conspirators  with  electrical  appliances. 

A  third  case  was  that  of  a  husband  and  wife,  who  both  became 
typical  cases  of  melancholia,  with,  of  course,  similar  delusions,  one 
shortly  after  the  other.  Such  a  case  as  this  might  be  called  a  coinci- 
dence, and  not  an  imposed  insanity.  Probably  grief  over  the  insanity 
of  the  husband  was  one  factor  in  developing  that  of  the  wife,  but 
unconscious  emotional  imitation  between  two  persons  united  by  special 
bonds  of  sympathy  was  undoubtedly  another  element. 

A  fourth  example  I  detailed  fully  some  years  ago  in  the  "  Alienist 
and  Neurologist"  ("  Paranoia  in  Two  Sisters."  January,  1890)  : 

C.  K.  and  H.  K.  were  respectively  thirty-six  and  forty-two  years  of 
age,  teachers  of  music  and  singers  by  occupation,  of  German  parentage, 
and  had  both  been  insane  for  some  ten  years.  Their  mother  was  a  case 
of  paranoia,  with  fixed  delusions  of  an  exalted  religious  nature.  She 
believed  herself  to  be  the  mother  of  God.  She  was  never  in  an 
asylum,  but  lived  at  home  until  her  death.  While  insane  she  gave 
birth  to  the  younger  of  the  two  sisters,  C.  K. 

One  of  them  wrote  for  me  an  autobiographical  sketch,  and  the  other 
some  twenty-five  letters,  upon  which  the  following  facts  in  their  identi- 
cal clinical  history  are  based  : 

The  instigators  of  the  conspiracy  against  them  are  chiefly  their 
uncle,  brother-in-law,  and  sister-in-law,  and  a  brother  has  also  been 
inveigled  into  it.  By  them  are  employed  numerous  detectives,  expert 
chemists,  and  handicraftsmen,  and,  as  they  have  privately  hinted  to  me, 
also  many  lawyers.  Openings  are  made  in  their  rooms  in  spite  of  all 
they  can  do  for  the  insufflation  of  noxious  gases,  smoke,  camphorous, 
chloral,  and  chloroform  vapors  ;  and  by  some  unseen  agency  substances 
are  thrown  at  them  which  produce  painful  cutaneous  eruptions.  Their 
food  and  water  and  heating  apparatus  are  tampered  with  for  the  intro- 
duction of  poisons  or  to  produce  serious  illness.  They  hear  the 
mechanics  at  work  upon  the  floors,  walls,  ceilings,  and  the  voices  of  the 
detectives  (hallucinations  of  hearing).  Their  food  has  a  peculiar  taste 
(hallucinations  of  taste).      Most  prominent  of    all  are  the   singular 


GENERAL   ETIOLOGY  OF  INSANITY.  DM 

odors  of  the  room,  of  fruit  and  flowers  sent  them,  of  the  water  (hallu- 
cinations of  smell).  Sometimes  they  are  black  in  the  morning  when 
they  look  in  the  mirror  (illusion  of  sight).  They  arc  subjed  to  remark- 
able, generally  painful,  sensations  in  their  bodies  (hallucinations  and 
illusions  of  cutaneous  sensibility). 

They  hint  of  imaginary  property  in  Germany,  out  of  which  they 
are  being  defrauded  by  relatives.  For  ten  or  twelve  yen-  they  have 
been  driven  from  one  place  to  another  in  Brooklyn  and  New  York  by 
their  pursuers.  As  yet  they  have  sought  only  escape  and  protection 
from  persecution  ;  they  have  very  rarely  manifested  anger  by  pounding 
the  floor  when  hearing  the  mechanics  at  work  or  by  complaint  to  the 
landladies,  and  have  not  been  brought  to  bay  to  a  condition  in  which 
they  might  turn  upon  the  actual  instigators  of  the  conspiracy  and  do 
them  bodily  harm.  They  have  been  on  the  point  of  a  visit  to  police 
headquarters  to  make  declaration  against  their  enemies. 

From  what  I  can  learn  of  their  history  in  youth  the  two  girls 
differed  from  others  of  their  age  in  a  slight  degree,  some  trifling  eccen- 
tricities and  some  overweening  self-consciousness  constituting  this 
difference.  They  have  always  been  closely  united — living  together, 
sleeping  together,  having  the  same  affinities,  talents,  pleasures,  and  pur- 
suits. The  development  of  suspicions  and  delusions  of  persecution  had 
been  so  gradual  that  it  did  not  become  evident  to  others  that  they  were 
actually  insane  until  a  comparatively  recent  period.  When  I  first  saw 
them  in  my  office,  they  came  heavily  veiled,  and,  upon  removing  their 
veils,  their  faces  were  patched  all  over  with  small  square  pieces  of 
cloth,  covering  sores.  These  were  only  an  ordinary  acne,  made  much 
worse  by  picking,  by  wearing  wet  cloths  on  their  faces  all  night  for  the 
purpose  of  preventing  poisonous  vapors  from  entering  their  lungs,  and 
by  the  removal  of  the  strongly  adhering  pieces  of  linen  from  the  bleed- 
ing surfaces.  They  healed  up  rapidly  when  I  had  prevailed  upon  them 
to  make  use  of  ung.  zinci  ox.  freely.  The  face  of  the  younger  is  par- 
ticularly characteristic  of  a  degenerate  type,  one  of  its  features  being  a 
disagreeable  prognathism. 

Some  of  the  skull  diameters  were  pathological  in  character.  One 
of  the  sisters  died  in  convulsions  from  unknown  cause,  which  the  other 
sister  still  attributes  to  poison.  The  living  sister  still  moves  about  from 
one  part  of  the  city  to  another,  cherishing  the  paranoiac  delusions,  but 
supporting  herself  in  part  by  teaching  music. 


648  MENTAL  DISEASES. 


CHAPTER  III. 
GENERAL  SYMPTOMATOLOGY  OF  INSANITY. 

Every  psychic  phenomenon  is  accompanied  by  a  material  process 
in  the  cortex  of  the  brain.  There  is  no  insanity  without  disease  of  the 
cortex.  The  material  disorder  of  the  cortex  is  diffuse  and  partly 
organic,  but  mostly  functional  in  character.  We  term  it  functional,  for 
thus  far  our  pathologico-anatomical  and  clinical  studies  have  failed  to 
reveal  any  definite  material  basis  for  the  majority  of  psychoses. 

The  progress  made  of  late  years  in  the  study  of  physiological  psy- 
chology has  illuminated  many  obscure  features  of  morbid  psychology, 
and  has  put  us  in  a  position  to  better  examine  and  classify  the  symp- 
toms of  insanity. 

There  are  material  processes  in  the  central  nervous  system  unaccom- 
panied by  any  parallel  psychic  process.  The  reflexes  and  automatic 
acts  are  examples.  In  these  phenomena  we  observe  a  stimulus,  a  sen- 
sation, a  movement.  Movement  paralleled  by  a  psychic  process  be- 
comes action.  We  sometimes  speak  of  conscious  voluntary  action. 
Action  differs  from  simple  movement  in  being  accompanied  by  intercur- 
rent images — memory-pictures  of  former  stimuli.  A  peripheral  stimulus 
excites  a  cortical  center,  and  is  not  carried  at  once  to  the  motor  region, 
but  travels  first  by  association  fibers  to  the  area  in  which  are  stored  up 
residua  of  former  similar  stimulations,  and  later  to  the  motor  region. 
These  residua  of  memory-pictures  or  ideas  may  be  complex,  constitute 
a  series,  have  many  associations,  and  hence  we  designate  them  as  an 
idea-association.  Action,  therefore,  consists  of  the  series  :  stimulus, 
sensation,  idea-association,  movement.  The  various  ideas  thus  excited 
tend  to  different  motor  expressions,  so  that  the  resulting  movement  or 
action  will  depend  directly  upon  the  strength  of  ideas.  The  stronger 
ones  conquer.  Ziehen,  whose  clear  explication  of  the  mental  problems 
of  psychiatry  the  writer  closely  follows,1  has  well  described  idea-asso- 
ciation as  the  play  or  battle  of  motives.  He  gives  the  following  exam- 
ple of  the  physical  and  psychic  processes  just  described  : 

I  see  a  rose  in  a  strange  garden  (stimulus  and  sensation).  A  long 
series  of  ideas  is  aroused  by  the  stimulus  and  the  visual  sensation  of 
the  flower  (idea-association).  For  instance,  the  memory  of  the  rose's 
fragrance  comes  to  mind,  then  I  think  how  well  it  would  look  in  my 
room,  that  it  is  the  property  of  another,  that  plucking  it  would  be 
punishable,  and  so  on.  Only  after  the  whole  series  of  presentations  has 
passed  before  the  mind  does  action  follow,  and  whether  I  pluck  the 
flower  or  go  my  way  without  it  will  depend  upon  the  strength  and 
intensity  of  the  conquering  idea. 

Every  psychic  process  must  be  regarded  upon  the  basis  of  such  a 

1  "Psychiatrie,"  Th.  Ziehen,  Berlin,  1894. 


GENERAL  SYMPTOMATOLOGY  OF  INSANITY.  649 

scheme,  and  as  accompanied  by  its  materia]  parallel  (progress  from  the 
sensory  cells  to  the  idea-cells,  and  from  these  to  motor-cells  by  means 
of  association-fibers). 

Sometimes  the  idea  of  movement  (memories  of  former  sensations  of 
movement)  comes  before  the  movement  in  the  series  jus!  described,  but 
generally  the  movement  is  perceived  after  it  has  taken  place  by  means 
of  the  sensation  of  the  movement. 

There  are  really  but  two  psychological  elements — viz.,  sensation  and 
idea.  The  only  process  connected  with  these  elements  is  the  idea- 
association.  Their  product  is  action.  The  so-called  mental  powers  of 
old-time  psychology  do  not  exist.  The  assumption  of  a  special  power 
of  will  dominating  the  idea-association  and  voluntarily  determining  this 
or  that  movement  is  particularly  superfluous  and  misleading.  The 
assumption  of  a  special  power  of  apperception  which  turns  its  "atten- 
tion" voluntarily  upon  this  or  that  idea  or  sensation  to  determine  the 
course  of  the  idea-association  is  equally  superfluous. 

The  presentations  or  ideas  rather  follow  one  another  according  to  laws 
without  intervention  of  any  especial  voluntary  power  of  the  mind,  and 
the  final  movement  or  action  is  the  necessary  result  of  association  of 
these  presentations  or  ideas.  Finally,  there  exists  no  particular  faculty 
of  feeling,  for  exact  investigation  demonstrates  that  our  feelings  of 
what  is  agreeable  and  what  is  distasteful,  of  pleasure  and  pain,  appear 
never  in  an  isolated  state,  but  always  combined  with  sensation  and  idea 
as  attributes  or  properties.1 

Following  Ziehen  in  these  particulars,  we  shall  study  pathological 
psychological  processes  on  the  basis  of  the  scheme  just  described,  and 
in  each  case  investigate,  first,  disorders  of  sensation  ;  then,  disorders  of 
the  memory-pictures,  presentations,  or  ideas ;  then,  again,  disturbances 
of  the  idea-association  ;  and,  finally,  the  influence  of  these  disturbances 
upon  the  actions  or  conduct  of  the  patient. 


DISORDERS  OF  SENSATION. 

Sensation  is  the  first  element  in  the  psychic  process.  It  is  deter- 
mined by  some  external  stimulus  affecting  any  sensory  nerve.  Every 
sensation  has  four  important  attributes — viz.,  quality,  intensity,  tone  (the 
accompanying  feeling  of  pleasure  or  pain),  and  space-projection.  We 
are  not  especially  concerned  with  the  last  in  morbid  psychology. 

Qualitative  Disorders  of  Sensation. — The  two  important  classes 
of  qualitative  disorders  of  sensation  are  hallucinations  (in  which  we  have 
sensation  without  external  stimulus)  and  illusions  (in  which  we  have  the 
external  stimulus,  but  a  transformed  or  perverted  sensation).  An  ex- 
ternal stimulus  to  a  peripheral  nerve  is  carried  to  the  cortex,  where  it 
acts  as  a  secondary  stimulus  in  exciting  sensation. 

Hallucinations. — A  hallucination  is  a  sensory  impression  without 
external  stimulus.     It  is  often  also  defined  as  a  perception  without  an 

1  "  Leitfaden  tier  physiologischen  Psychologie, "  von  Th.  Ziehen,  Jena,  1893. 


650  MENTAL  DISEASES. 

object.     The  patient  hears  voices  where  all  is  silent,  sees  forms  and 
figures  in  empty  space. 

Hallucinations  of  sight  are  very  common,  and  vary  from  the  simplest 
sparks,  lights,  shimmers,  flames,  spots,  threads,  clouds,  and  shadows  to 
the  most  complicated  groups  of  persons  and  landscapes  with  perfect 
details.  Sometimes  they  are  colorless,  like  silhouettes  ;  sometimes  radi- 
ant and  fantastic  with  color.  Sometimes  they  are  flat,  like  pictures ; 
sometimes  plastic.  Ordinarily,  the  forms  and  objects  observed  are  of 
natural  size,  but  occasionally  they  are  gigantic  or  diminutive.  They 
may  appear  close  at  hand  or  far  away.  They  may  be  quiet  or  full  of 
movement,  like  the  zooscopic  hallucinations  of  alcoholism.  Harely, 
real  objects  are  doubled  or  multiplied  (hallucinatory  diplopia  and  poly- 
opia). Real  objects  are  sometimes  concealed  by  the  hallucinations, 
sometimes  merely  diaphanously  veiled.  Hallucinations  may  fill  the 
whole  field  of  vision  or  appear  in  homonymous  half-fields,  as  in  the 
hemiopic  hallucinations  described  by  the  writer  in  cases  of  insanity  and 
of  homonymous  hemianopsia.1 

Hallucinations  of  hearing  are  also  extremely  frequent,  and  vary 
from  simple  sounds,  tinnitus  aurium,  rushing,  roaring,  whispering, 
tinkling,  to  complicated  music  and  words  and  sentences.  These  last 
may  be  in  natural  tone  or  deep-voiced,  whispered  or  loud ;  may  be  the 
voice  of  one  or  many  persons  ;  may  be  pronounced  in  various  languages  ; 
may  be  single  words  or  long  orations ;  may  seem  near  at  hand  or  far 
removed  ;  and  may  be  heard  in  one  ear,  though  usually  in  both.  Not 
infrequently  the  voice  seems  to  the  patient  so  near  that  it  appears  to  be 
in  his  head  or  body. 

Hallucinations  of  common  cutaneous  sensibility  may  appear  any- 
where in  the  skin  or  in  mucous  membranes  in  the  form  of  electric 
shocks,  pricking,  tingling,  blows,  caresses,  sensations  of  heat  or  cold, 
indignities  to  the  sexual  organs  (feeling  of  cohabitation),  etc. 

Hallucinations  of  smell  are  very  common.  The  patients  perceive 
odors  of  chloroform,  sulphur,  noxious  gases,  smoke,  filth,  or,  on  the 
other  hand,  the  smell  of  perfumes  and  flowers. 

Hallucinations  of  taste  are  so  generally  combined  with  those  of 
smell,  because  of  the  close  physiological  relation  of  the  two  senses,  that 
true  hallucinations  of  the  primary  elements  of  taste  (salt,  sweet,  bitter, 
and  sour)  are  uncommonly  rare.  A  hallucination  of  a  bitter  taste  is 
the  most  frequent.  On  the  other  hand,  the  combined  hallucination  of 
taste  and  smell  (as  of  blood,  filth,  etc.)  is  rather  common. 

Hallucinations  of  organic  sensation  are  not  rare.  The  patients  com- 
plain of  peculiar  or  extraordinary  feelings  in  various  organs,  such  as- 
malposition,  gnawing,  cutting,  pain,  etc. 

Hallucinations  of  active  or  passive  movement  of  the  body  or  its 
parts  depend  probably  chiefly  upon  disorders  of  joint  sensibility.  The 
patients  feel  themselves  lifted  in  the  air,  floating,  the  limbs  moved 
actively,  the  head  turned  to  one  side  ;  or,  the  sensation  of  movement  of 

1  "  Homonymous  Hemiopic  Hallucinations,"  "  N.  Y.  Med.  Jour.,"  August  30,. 
1890.  A  second  note  on  "Homonymous  Hemiopic  Hallucinations,"  "N.  Y.  Med. 
Jour.,"  January  31,  1891. 


GENERAL  SYMPTOMATOLOGY  OF  INSANITY.  651 

the  muscles  required   for  speech  may  give  rise  to  the  hallucination  of 
having  spoken  a  word  or  sentence. 

Various  hallucinations  are  often  associated  in  such  a  manner  a-  to 
render  the  hallucinated  objects  still  more  natural  and  deceptive,  though 
more  frequently  they  are  not  thus  commingled.  Thus,  visionary 
figures  may  speak  or  be  dumb,  and  the  fancied  voice-  may  come  from 
visually  projected  or  from  unseen  persons.  Sometimes  vision,  hearing, 
and  cutaneous  sensation  may  be  combined  to  give  reality  to  the  object. 
Combinations  of  others  are  also  met  with,  and,  indeed,  these  mixed 
hallucinations  are  common  and  multiform. 

As  regards  the  development  of  hallucinations,  some  are  doubtless 
peripheral,  but  the  majority  are  central  in  their  origin.  Disorders  of 
the  eye,  ear,  nasal  cavity,  mouth,  mucous  membranes,  skin,  and  viscera 
may  give  rise  to  hallucinations,  though  they  are  more  commonly  the 
cause  of  illusions.  Hallucinations  are  never  new  creations,  but  are  made 
up  of  memory-pictures  stored  up  in  the  cortex  ;  these  may,  however, 
make  their  appearance  in  new  combinations.  The  congenitally  blind 
never  have  visual  hallucinations ;  the  congenitally  deaf  never  auditory 
hallucinations,  though  they  are  noted  in  acquired  blindness  and  deafness. 

Hallucinations  are  usually  of  two  kinds — those  which  have  to  do 
with  the  ideas  presented  in  the  mind  at  the  time  of  their  manifestations, 
and  those  which  are  concerned  with  latent  memory-pictures.  The 
former  are  more  common,  but  both  may  be  observed  in  the  same 
patient.  The  first  kind  are  those  which  the  patient  describes  as 
visions  which  picture  his  very  ideas,  and  voices  which  read  off  his 
thoughts  as  fast  as  they  can  come  into  his  mind — indeed,  often  appar- 
ently before  he  thinks  them.  The  second  class  of  hallucinations  often 
astounds  the  patient  by  association  with  things  long  past  and  quite 
forgotten. 

We  are  taught  by  physiological  psychology  that  a  stimulus  to  the 
eye  arouses  a  sensation  in  the  occipital  lobe,  to  the  ear  a  sensation  in  the 
temporal  lobe,  and  so  on,  the  sensation  further  exciting  an  image  which 
remains  as  a  memory-impression.  All  normal  sensations,  then,  depend 
upon  the  series  stimulus,  sensation,  memory-picture,  or  idea.  Now, 
hallucinations  are  always  cortical,  as  regards  localization,  and  depend 
upon  a  reversal  of  the  normal  course  just  described,  and  without  the 
stimulus.  The  memory-image  is  excited  and  then  excites  the  sensation. 
A  certain  irritability  of  these  centers  will  be  induced,  undoubtedly, 
by  morbid  processes  in  the  peripheral  nerves  or  their  terminations, 
such  as  entoptic  or  entotic  processes,  which  will  render  them  all  the 
more  excitable,  since  external  stimulus  is  not  then  altogether  wanting. 
Finding  such, — and  we  should  always  investigate  carefully  for  a  periph- 
eral physical  basis, — the  dividing-line  between  hallucinations  and  illu- 
sions becomes  less  distinct.  Naturally,  the  normal  mind  recognizes  the 
real  nature  of  musese  volitantes,  tinnitus  aurium,  neuralgic  pains,  etc., 
and  it  is  only  the  abnormal  mind  which  employs  them  as  material  for 
illusions  and  hallucinations. 

In  the  examination  of  a  patient  we  must  determine  the  presence  of 
hallucinations  and  the  effect  of  their  presence  on  idea-association.     One 


'652  MENTAL   DISEASES. 

must  not  mistake  actual  occurrences  described  by  the  patient,  nor  the 
events  of  dreams  confused  by  him  with  events  of  waking,  nor  ordinary 
illusions  for  hallucinations.  There  is  danger,  too,  of  overlooking  their 
presence.  Patients  conceal  them,  conscious  that  the  hallucinations  are 
morbid,  or  knowing  that  they  will  be  looked  upon  as  such,  but  will 
often  write  about  them  or  tell  of  them  to  other  patients  if  opportunity 
be  given.  Very  often  the  physician  is  enabled  to  recognize  their  exist- 
ence from  the  expression  and  conduct  of  the  patient. 

As  regards  the  influence  of  hallucinations  upon  the  course  of  idea- 
association,  the  most  important  question  is  whether  they  are  regarded 
by  the  patient  as  real  sensations  or  not.  He  treats  them  as  actual 
phenomena,  as  if  they  were  normal  sensations,  or  he  distinguishes  them 
from  his  ordinary  sensations  as  peculiar,  novel,  and  possibly  inspired  by 
supernatural  agencies  ;  or  he  is  really  conscious  of  their  morbidity,  but 
may  believe  them  to  be  induced  by  enemies  by  means  of  poison.  If  the 
hallucinations  are  faint  and  transitory,  the  patient  may  not  be  much  in- 
fluenced by  them  ;  if  they  are  marked  and  persistent  for  a  long  period, 
he  ultimately  loses  his  critical  faculty  and  comes  to  believe  in  their 
reality.  Such  being  the  case,  his  thought  and  conduct  are  bound  to  be 
influenced  by  them,  and  more  powerfully  influenced  than  by  normal 
sensations,  or  by  any  reasonable  consideration  or  argument.  Hallucina- 
tions either  inhibit  (hallucinatory  stupor)  or  retard  (hallucinatory  con- 
fusion) the  idea-association  ;  or  they  induce  direct  intrinsic  delusions  (as 
when  a  voice  cries  "  Thou  art  God,"  and  the  patient  immediately  be- 
lieves himself  to  be  God).  The  actions  and  conduct  of  a  patient  are 
very  much  influenced,  and  in  multiform  ways,  by  hallucinations.  He 
has  the  expression  of  listening,  or  stares  apparently  at  nothing.  He 
closes  his  ears,  covers  his  eyes  or  head,  closes  up  cracks  and  openings, 
or  listens  at  the  window  or  keyholes.  He  refuses  or  spits  out  his  food. 
He  holds  his  nose,  or  suddenly  closes  the  window  to  prevent  the  entrance 
of  noxious  gases.  He  turns  his  head,  runs,  shouts,  lifts  his  arm  quickly, 
or  takes  peculiar  attitudes,  acting  upon  a  hallucination  of  muscular 
sense  (imperative  movements,  imperative  speech,  imperative  attitudes). 
The  imperative  attitudes  may  be  very  persistent  and  long-continued,  and 
are  then  called  catatonic.  Hallucinations  often  lead  to  imperative  acts 
which  may  be  of  a  violent  nature.  If  hallucinations  are  innumerable, 
very  changeable,  and  intense,  the  patient  is  affected  by  so-called  hallu- 
cinatory agitation. 

Hallucinations  are  so  extremely  rare  under  normal  conditions  that 
they  are  to  be  considered  as  almost  always  pathological.  Illusions  are 
rather  common  in  the  normal  mind.  True  hallucinations  may  occur  in 
apparently  normal  individuals,  but  examination  will  show  that  such 
persons  are  neurotic  by  heredity,  and  that  some  stress  of  mind  or  body 
has  induced  this  psychopathic  phenomenon.  This  is  particularly  true 
in  childhood. 

Outside  of  the  psychoses,  hallucinations  are  met  with  in  toxic  states, 
fevers,  cachectic  conditions,  sun-stroke,  and  some  of  the  neuroses  (epi- 
lepsy, chorea,  hysteria).  A  hallucination  of  any  sense  may  be  the  aura 
of  an  epileptic  attack  ;  sometimes,  when  visual,  it  may  be  hemiopic. 


GENERAL  SYMPTOMATOLOGY  OF  INSANITY.  653 

Hallucinations  are  the  chief  symptom  of  one  form  of  paranoia. 
Other  psychoses,  such  as  mania  and  melancholia,  manifest  them  only 
exceptionally;  while  still  others,  like  senile  and  paretic  dementia,  pre- 
sent hallucinations,  it  is  true,  but  not  in  such  prominence  as  to  make 
them  a  characteristic  symptom.  Visual  hallucinations  are  more  com- 
mon in  acute  than  in  chronic  psychoses,  and  they  are  seldom  indepen- 
dent of  hallucinations  of  feeling  and  hearing.  Auditory  hallucinations, 
on  the  other  hand,  are  more  characteristic  of  chronic  types  of  mental 
disorder,  and  are  often  observed  alone. 

The  close  union  of  the  auditory  center  with  the  motor  speech  center 
gives  a  peculiar  interest  to  hallucinations  of  hearing.  From  infancy 
man  is  trained  to  think  to  a  great  extent  in  word-images  or  speech- 
images,  and  thinking  is,  therefore,  nearly  always  associated  with  some 
stimulation  of  the  speech-muscle  centers  in  the  brain.  Therefore,  hal- 
lucinatory irritation  in  the  auditory  area  of  the  brain  causes  synchronous 
irradiation  to  the  motor  speech  center,  and  words  and  sentences  are 
heard  by  the  hallucinant  as  if  projected  into  the  external  world,  or  into 
some  part  of  the  patient's  body  (head,  throat,  chest,  stomach,  or  even 
extremities).  The  stimulation  of  the  speech  muscles,  however  feeble, 
may  be  sufficiently  strong  to  induce  recurrent  sensations  of  movement 
in  them,  which  leads  the  patient  to  imagine  that  his  thoughts  are  being 
read  off  internally  by  the  voice,  and  sometimes  repeated  apparently 
before  the  thought  has  fully  developed  in  his  brain. 

Illusions. — An  illusion  is  a  false  perception.  There  is  a  stimulus 
but  a  perverted  sensation,  a  wrong  interpretation.  The  sensation 
corresponds  only  in  part  to  the  stimulus.  A  patient  hears  the  rain 
falling,  but  perceives  it  as  music ;  he  sees  the  bedpost,  but  imagines  it 
a  ghost. 

Visual  illusions  exhibit  a  transformation  of  form,  or  color,  or  both. 
This  is  often  favored  by  indistinctness  of  outline,  as  when  it  is  half  dark 
or  there  is  a  shimmering,  flickering  light.  But  often  clear  outlines  are 
transformed.  The  patient  may  see  the  familiar  faces  about  him  changed 
into  those  of  strangers,  transformed  by  grimaces,  or  deathly  pale.  A 
sharp  distinction  between  illusory  transformation  and  actual  hallucina- 
tion is  often  difficult  to  draw.  It  is  peculiar  to  illusions  that  they  not 
infrequently  present  objects  as  distorted  and  diminished  or  increased  in 
size.  This  is  especially  true  among  epileptics.  When  this  is  noted 
with  all  objects,  it  often  depends  upon  entoptic  disorders.  Thus,  meta- 
morphopsia  may  arise  from  astigmatism  and  retinal  disease,  micropsia 
from  paresis  of  accommodation,  and  macropsia  from  spasm  of  accommo- 
dation. When  this  is  not  the  cause,  perverted  association  of  the  sensa- 
tion, with  disordered  muscular  sense,  may  play  a  role.  Sometimes, 
though  rarely,  the  illusion  may  consist  of  a  perversion  of  color  analogous, 
for  instance,  to  the  yellow  appearance  of  objects  in  santonin-poisoning 
(due  to  violet  blindness  induced  by  the  poison)  or  to  red  vision  (ery- 
thropsia  induced  by  fatigue  of  the  retina  for  the  short-waved  rays  of  the 
violet  side  of  the  spectrum). 

Illusions  of  hearing  consist  mostly  of  the  construction  of  words  out 
of  inarticulate  sounds,  or  of  the    misinterpretation    of  the   words   or 


654  MENTAL   DISEASES. 

sentences  spoken  in  the  patient's  hearing.  He  may  transform  them  into 
mocking,  indecent,  derogatory,  or  flattering  words. 

Illusions  of  common  sensibility  are,  perhaps,  more  important  in 
insanity  than  hallucinations  of  this  sense.  But  they  are  difficult  to 
study  and  establish.  It  is  probable  that  the  sandy,  earthy  taste  of  food 
often  complained  of  by  patients  is  more  an  illusion  of  touch  than  of  taste. 

Illusions  of  smell  and  taste  are,  in  the  main,  unpleasant  in  character 
and  are  more  common  than  hallucinations  of  these  senses. 

Illusions  of  organic  sensation  are  frequently  noted,  and  consist  of  such 
sensory  metamorphoses,  for  instance,  as  the  mistaking  of  intestinal 
motions  for  pregnancy,  and  the  feeling  of  diminution  or  increase  in  size 
of  various  organs  (particularly  noticeable  in  epilepsy  and  paresis). 

Illusions  of  muscular  sense  or  of  movement  are  rare. 

Illusions,  like  hallucinations,  may  form  their  material  from  the 
concepts  at  the  moment  in  consciousness,  or  from  latent  memory -pictures. 

The  theory  of  the  cause  of  illusions  is  analogous  to  that  of  hallucina- 
tions. They  arise  from  a  pathological  recurrent  influence  of  the  excited 
memory-picture  cells  upon  the  sensory  cells.  The  difference  lies  in  the 
association,  also,  of  an  actual  external  stimulus  which  undergoes  trans- 
formation. 

Illusions  are  much  more  common  than  hallucinations,  and  are  not 
seldom  met  with  in  normal  persons.  Often  they  are  difficult  to  dis- 
tinguish from  one  another.  Sometimes  it  is  impossible  to  differentiate 
true  illusions  from  so-called  illusionary  judgments,  in  which  we  are 
concerned  not  so  much  with  a  transformation  of  sensation,  as  with  an 
erroneous  judgment  of  the  character  of  a  normal  sensation. 

Illusions  are  noted  in  all  forms  of  psychoses,  especially  in  acute 
forms.  They  are  particularly  noteworthy  in  the  hallucinatory  form  of 
paranoia. 

Disorders  of  Intensity  of  Sensation. — These  consist  of  hypesthe- 
sias,  anesthesias,  and  hyperesthesias.  Hypesthesias  and  anesthesias  are 
observed  in  various  psychoses  which  are  complicated  by  such  disorders 
as  hysteria,  chorea,  multiple  neuritis,  tabes,  focal  cerebral  lesions,  etc. 
Hyperesthesia  is  also  encountered  in  complicating  disorders,  such  as  hys- 
teria, tubercular  meningitis,  neurasthenia ;  but  is  also  often  noted  in  the 
prodromal  stages  of  many  acute  psychoses.  It  is  especially  remarkable 
in  the  insanities  of  childhood.  A  valuable  objective  sign  of  hyper- 
esthesia is  exaggeration  of  the  superficial  reflexes. 

Disorders  of  Sensory  Tone. — Agreeable  or  disagreeable  feeling, 
associated  with  sensation,  is  described  as  sensory  tone.  Sensory  tone  may 
be  perverted  in  insanity  so  that,  for  instance,  fragrance  is  perceived  as 
unpleasant,  dissonance  as  pleasant,  and  vice  versa.  One  notes  such  per- 
versions in  the  slight  psychopathic  conditions  of  pregnancy  in  the  form 
of  capricious  tastes  and  appetites.  Homosexual  perversion  is  a  form  of 
this  disorder  manifested  in  the  domain  of  sexual  sensation.  Pathologi- 
cal disorders  of  the  intensity  of  sensory  tone  consist  of  hypalgesia  and 
analgesia,  hyperalgesia,  hyphedonia,  and  hyperhedonia. 

The  hypalgesias  are  noted  in  hysteria,  tabes,  congenital  and  acquired 
mental  deficiency,  and  in  severe  hallucinatory  confusion. 


<!  EN  Ell.  1  L  SYMPTOM,  i  TOLOG  7  OF  INS.  1  NITT.  655 

Hyperalgesia  is  observed  under  the  same  circumstances  as  hyper- 
esthesia. It  is  most  often  seen  in  hysterical  and  neurasthenic  insanities, 
and  almost  exceptionally  at  certain  points  (such  as  the  supraorbital, 
infraorbital,  mental,  Valleix,  iliae,  intercostal,  mammary,  vertebral,  and 
cranial  suture  points)  pressure  elieits  pain.  The  pain  of  hunger,  which 
leads  in  many  psychoses  to  pathological  hunger  (bulimia)  belongs  in 
this  category. 

Hyphedonia  is  a  morbid  diminution  of  the  feeling  of  pleasure  in  any 
sensory  perception.  It  is  more  important  in  the  domain  of  sexual  .-<-n- 
sations  than  in  others,  where  it  may  reach  the  degree  of  anhedonia. 
Sexual  anhedonia  is  not  uncommonly  developed  on  the  basis  of  a  seri- 
ous hereditary  degeneracy,  and  is  frequent,  too,  in  organic  disease  of 
the  central  nervous  system  (tabes  and  paresis),  as  well  as  in  toxic  con- 
ditions (alcohol,  coeain,  morphin).  Hyphedonia,  in  connection  with 
hunger  sensations,  may  reach  the  state  of  complete  psychic  anorexia  in 
some  insanities. 

Hyperhedonia  is  a  morbid  increase  of  positive  sensory  tone  (agree- 
ability  of  sensation),  and  is  noted  most  often  in  relation  to  sexual 
sensations. 

Disorders  of  Memory-pictures  or  Ideas. — Every  stimulus  in 
arousing  a  sensation  in  the  cerebral  cortex  leaves  some  material  vestige 
or  impression,  which  remains  as  a  latent  memory-image  or  picture, 
latent  presentation,  or  idea.  Countless  numbers  of  memory-pictures  left 
by  innumerable  sensations  of  all  kinds  are  stored  away  as  a  material 
deposit  in  the  brain-cortex.  These  are  rearoused  either  by  the  same  or 
a  similar  stimulus,  or  excited  through  the  stimulus  of  some  idea- 
association.  Only  a  few  of  the  millions  of  memory -pictures  are 
awakened  to  life  at  any  one  moment ;  all  of  the  others  remain  latent. 
The  general  concept  of  any  particular  object  is  made  up  of  the  associa- 
tion of  many  centers  in  the  brain,  some  of  which  are  far  apart,  such  as 
the  smell,  feel,  taste,  color,  sound,  and  name  of  the  object.  The  rela- 
tion of  this  object  to  others  of  its  kind  is  present  in  other  associations, 
and  these  again  in  others,  so  that  the  material  basis  of  an  idea  must  be 
a  perfect  network  of  association  fibers ;  and  all  of  this  labyrinth  is  con- 
nected with  the  complex  series  of  language-centers,  but  particularly 
with  the  motor  and  auditory  speech-centers,  which  are  trained  up  from 
earliest  infancy  to  associate  the  spoken  word  with  the  concrete  concep- 
tion. A  word,  therefore,  expresses,  like  an  algebraic  x,  y,  or  z,  some 
very  intricate  and  complicated  formula.  Take  words  like  "home/' 
"  right,"  "  wrong,"  and  so  on,  and  think  what  a  countless  number  of 
associated  memory-pictures  each  one  must  represent !  Words  are 
simply  convenient  abbreviations  which  render  more  easy  the  use  of  con- 
cepts in  idea-associations. 

We  distinguish  in  every  idea  four  cardinal  properties  :  (1)  The  con- 
tents or  meaning ;  (2)  distinctness ;  (3)  associated  affects ;  (4)  energy 
or  intensity. 

The  pathological  disturbances  of  ideas  may  be  studied  under  the 
headings  of  disorders  of  their  evolution,  durability,  concomitant  aifects 
and  associations. 


656  MENTAL   DISEASES. 

Defective  Evolution  of  Ideas. — The  number  of  concepts  stored  up 
in  the  brain  varies  enormously  under  normal  conditions  with  individuals 
and  races.  In  morbid  psychology  we  find  the  number  of  ideas  extremely 
small  among  congenital  defectives,  such  as  the  idiot,  the  imbecile,  and 
the  feeble-minded.  The  idiot  may  preserve  rudimentary  memory- 
pictures  of  the  simplest  things,  such  as  food  and  eating,  light,  dark- 
ness, clothing,  but  without  speech  associations ;  he  will  have  none  of 
other  persons  or  other  objects  about  him.  In  the  imbecile  the  concepts 
are  more  numerous  and  may  be  known  by  name  ;  he  recognizes  persons 
and  objects,  distinguishes  simple  colors  with  difficulty,  may  have 
number  concepts  as  high  as  ten ;  he  has  a  few  concrete  ideas,  but,  as  a 
rule,  no  abstract  ideas.  The  feeble-minded  has  a  larger  number  of 
memory-pictures,  may  have  abstract  ideas,  recognizes  the  significance  of 
likeness  and  similarity,  and  may  use  the  words  God,  right,  wrong,  etc., 
but  in  reality  be  unable  to  tell  the  meaning  of  such  complex,  abstract 
conceptions.  It  is  necessary,  therefore,  to  avoid  concluding  that  the 
idea  is  present  because  the  word  is  spoken  by  such  a  patient,  for  it  is 
particularly  characteristic  of  the  congenitally  feeble-minded  to  be  apt 
with  words  while  deficient  in  grasp  of  their  meaning. 

Disorders  in  Durability  of  Memory-pictures. — The  forgetting  of 
a  memory-picture,  when  the  stimulus  and  sensation  producing  it  are  not 
repeated,  may  be  considered  to  be  due  to  its  gradual  erasure  by  the  in- 
fluence of  the  nutritive  processes  which  affect  the  cortical  ganglion-cells 
equally  with  all  the  elements  and  tissues  of  the  body.  This  physio- 
logical destruction  of  the  memory-picture  is  always  very  slow,  but  by 
pathological  processes  may  be  rendered  enormously  rapid.  The  de- 
struction may  be  diffuse  or  limited  to  one  sensory  sphere  (for  example, 
apraxia,  where  the  sensory  ideas  of  objects  are  lost,  though  the  sensory 
apparatus  may  be  intact ;  mind-blindness,  word-blindness,  mind-deaf- 
ness, word-deafness,  etc.).  But  these  limited  defects  of  memory-pictures 
are  due  to  focal  lesions  in  the  brain,  and  do  not  concern  the  alienist  so  much 
as  the  diffuse  destruction  of  ideas,  although  it  is  true  that  the  latter  may 
sometimes  be  a  sequel  to  a  circumscribed  lesion,  and,  on  the  other  hand, 
that  the  diffuse  disorder  may,  as  in  general  paralysis,  sometimes  affect 
one  region  more  than  another.  A  loss  of  concrete  ideas,  such  as  general 
concepts  of  relationship,  etc.,  which  are  represented  by  a  wide-spread 
association  network  in  the  whole  cortex,  can  only  be  caused  by  a  diffuse, 
far-reaching  disturbance.  We  see  examples  of  such  loss  in  the  acquired 
dementias  of  paresis,  epilepsy,  and  senility,  dementias  secondary  to 
acute  psychoses,  and  dementias  due  to  toxic  agents.  It  is  natural  that 
the  latest  memory  acquisitions  should  be  lost  first,  and  the  older  mem- 
ories successively  later,  in  direct  proportions  to  their  age,  according  to 
a  certain  "  law  of  regression,"  as  Ribot  terms  it.  This  is  to  be  ex- 
plained by  the  want  of  permanence  and  stability  in  the  newest  arrange- 
ment or  concatenation  of  protoplasmic  molecules  and  ganglion-cells. 
The  older  impressions  have  become  more  fixed  and  durable. 

Since  an  experience  leaves  behind  not  alone  a  single  memory-picture, 
but  a  whole  series  arranged  in  chronological  order,  we  may,  as  in  am- 
nesias, find  pathological  states  in  which  there  are  losses  of  such  series 


GENERAL  SYMPTOMATOLOGY  OF  INSANITY.  657 

of  ideas  during  a  definite  period  of  time.  The  so-called  subconscious 
or  unconscious  states  are  examples  of  this  phenomenon.  They  are 
observed  in  epilepsy,  intoxications,  hysteria,  narcolepsy,  hypnotism, 
somnambulism,  injuries  to  the  head,  and  in  transitory  insanity. 

Affective  Disorders. — Pleasurable  or  disagreeable  feelings  accom- 
pany ideas,  just  as  they  do  common  sensations  ;  so  that  there  i.~  an  intel- 
lectual affective  tone  analogous  to  sensory  tone,  if  two  ideas  be  pre- 
sented simultaneously,  and  if  one  of  these  have  a  stronger  emotional 
quality  than  the  other,  the  tone  of  this  will  be  irradiated  to  the  other. 
Ziehen, in  describing  irradiation, gives  the  following  example:  "If  I  have 
met  with  an  accident  in  any  place,  afterward  not  only  is  the  memory  of 
the  injury  accompanied  by  an  unpleasant  feeling,  but  the  memory  of 
the  place  is  likewise  mingled  with  a  disagreeable  affect.  Furthermore, 
when  I  again  see  the  spot  where  the  accident  occurred,  I  may  feel  again 
the  sensation  of  the  injury,  accompanied  by  its  unpleasant  sensory  tone." 
Here  the  memory-picture  arouses  the  sensory  tone  of  the  sensation  ex- 
perienced. This  is  termed  reflected  tone.  The  most  important  conse- 
quence of  the  laws  of  emotional  irradiation  and  reflection  is  that  if  in  a 
certain  period  of  time  one  or  several  sensations  and  ideas  have  a  strong 
and  similar  emotional  tone,  all  other  sensations  and  ideas  presented  to 
the  mind  during  the  same  period  of  time  will  be  colored  by  the  tone  of 
the  former.  Such  irradiation  creates  our  moods,  which  are  hence  the 
abstract  or  summary  of  the  similar  emotional  tones  of  the  ideas  and 
sensations  experienced  within  any  definite  period  of  time. 

Moods  and  emotions  influence  strongly  the  flow  of  our  ideas,  and,  as 
a  consequence,  our  actions.  Depressed  moods  or  affects  inhibit,  wdiile 
exalted  affects  increase  the  flow  of  ideas,  and  likewise  the  resultant 
actions.  Depressed  affects  are  more  durable  and  persistent  than  exalted 
affects.  The  latter  subside  rapidly.  The  more  complicated  ideas,  such 
as  justice,  honor,  law,  family,  patriotism,  etc.,  are  accompanied  by  a 
specific  affect  or  tone  which  we  designate  as  ethical  feeling.  Ethical 
feeling  is  the  result  of  numerous  irradiations,  which  the  single  idea 
acquires  from  all  of  the  ideas  associated  with  it ;  and  the  sum  of  the 
ethical  feelings  of  an  individual  gives  him  his  character  (Ziehen). 

In  morbid  psychology  we  classify  changes  in  the  affects  as  patho- 
logical depression,  exaltation,  irritability,  apathy,  and  mutability. 

Depression. — Depression  is  observed  in  many  forms  of  insanity, 
particularly  as  a  prodrome,  but  is  characteristic  of  the  melancholy  types. 
It  is  a  very  common  prodrome  of  acute  mania,  and  a  long  period  of 
morbid  depression  is  frequently  noted  as  an  antecedent  in  general 
paresis.  It  is  observed  in  neurasthenia,  in  hypochondriasis,  and  not 
seldom  as  an  interlude  in  any  psychosis.  It  is  the  cardinal  symptom 
of  melancholia.  Depression  is  a  normal  consequence  or  accompaniment 
of  sorrowful  or  dreadful  hallucinations  and  ideas,  and  is,  under  such 
conditions,  termed  secondary.  It  is  primary  depression  with  which  we 
are  more  concerned  in  insanity — a  depression  not  at  all  or  but  slightly 
motived  by  such  hallucinations  and  ideas  as  we  have  just  described, 
but  a  mood  which  takes  possession  of  the  mind  of  the  patient  and  gives 
its  own  original  color  to  every  thought  arising  in  his  mind  and  to  every 
42 


658  MENTAL  DISEASES. 

external  object  presented  to  his  consciousness.  Past,  present,  and 
future  are  alike  under  the  shadow  of  this  mood.  When  mild  in  degree, 
the  patient  feels  only  an  inexplicable  sadness — a  certain  restlessness  or 
state  of  worry  ;  but  when  extreme,  this  general  mood  of  sadness  be- 
comes a  condition  of  pathological  anxiety — a  mixed  feeling  of  grief  and 
dread,  often  accompanied  by  a  feeling  of  suffocation  or  pain  about  the 
heart,  and,  therefore,  frequently  designated  as  "  precordial  anxiety  "  or 
11  precordial  fright."  When  primary  depression  is  present,  the  patient 
feels  the  change  in  his  mental  condition,  observes  that  he  no  longer  is 
cheered  by  the  usual  pleasant  events  of  his  daily  life,  that  these  rather 
intensify  his  misery.  The  affection  and  sympathy  of  his  friends  and 
family  either  awaken  no  response  in  his  own  breast  when  he  tends  to 
believe  that  he  has  lost  all  natural  feeling,  or  they  may  awaken  sus- 
picion, dislike,  and  distrust.  The  inhibition  of  the  flow  of  thought 
restricts  his  ideas  to  himself  and  to  the  somber  contents  of  his  mind. 
He  is  not  easily  distracted  from  such  contemplation,  and  answers  ques- 
tions, if  at  all,  very  slowly  and  with  great  difficulty.  Nearly  all  cases 
with  morbid  depression  complain  of  disorders  of  visceral  sensibility, 
from  a  slight  sense  of  constriction  at  the  throat  to  precordial  distress, 
from  a  general  feeling  of  illness  and  uneasiness  to  a  feeling  of  extreme 
and  general  restlessness.  No  doubt  depression  influences  often  the 
entire  musculature  of  the  body,  so  that  the  patient  wrings  his  hands, 
picks  his  fingers  or  head,  walks  up  and  down,  is  extremely  agitated, 
goes  into  a  condition  of  catalepsy  or  catatonia,  or,  on  the  other  hand, 
remains  absolutely  immobile  and  requires  the  service  of  others  for  every 
movement.  The  muscles  of  the  peripheral  arteries  contract  and  in- 
crease the  frequency  of  the  heart's  action.  The  constriction  of  the 
throat  is  probably  an  actual  contraction  of  the  esophageal  muscles. 
Precordial  anxiety  is  most  likely  due  to  vasomotor  disturbance  in  the 
vessels  of  the  heart.  The  constipation  so  frequent  in  depressed  con- 
ditions depends  doubtless  upon  retardation  of  peristalsis.  Thus  we 
observe  in  one  case  motor  inhibition,  in  another  motor  excitement,  and 
in  some  alternations  between  the  two. 

In  seeking  to  explain  the  mood  of  sadness  and  uneasiness  which  he 
feels,  the  patient  tends  to  develop  delusions.  He  invokes  the  first  ideas 
which  would  naturally  come  to  him  under  such  circumstances.  He 
seeks  in  his  past  life  for  some  sin,  the  commission  of  which  may  have 
brought  this  punishment.  He  magnifies  some  trivial  error  in  his  youth 
into  an  unpardonable  sin.  Or  he  comes  to  think  that  poverty  stares 
him  in  the  face,  or  that  he  can  never  recover  from  an  incurable  illness 
which  has  taken  possession  of  him.  Occasionally,  a  persecutory  delusion 
is  evolved  from  a  primary  depression. 

Exaltation. — Exaltation  is  occasionally  noted  as  an  intercurrent 
symptom  in  any  psychosis.  It  sometimes  alternates  Avith  depression, 
forming  a  constant  cycle,  as  in  circular  insanity,  and  sometimes  it  pre- 
sents itself  during  convalescence  from  melancholia  as  a  reactive  phe- 
nomenon. In  the  majority  of  cases  of  general  paresis  a  period  of 
exaltation  develops.  In  maniacal  states,  however,  it  is  observed  as  a 
cardinal  symptom.     As  with  depression,  we  distinguish  a  secondary 


GENERAL  SYMPTOMATOLOGY  OF   INSANITY.  659 

exaltation  consequent  upon  agreeable  hallucinations  and  ideas,  and  a 
primary  or  unmotived  exaltation.  In  exalted  moods  the  somesthetic 
sensations  are  pleasurable  and  give  rise  to  feelings  of  perfect  health, 
.strength,  and  vitality.  The  stream  of  ideas  is  hastened,  and  as  a 
result  the  patient  becomes,  according  to  the  degree  of  exaltation,  talka- 
tive and  garrulous,  or  exhibits  a  veritable  logorrhea, — a  constant,  rapid 
flow  of  words, — which  may  often  assume  a  riming,  singing,  or  orator- 
ical character,  with  marked  incoherence.  The  rapid  stream  of  presen- 
tations is  paralleled  in  the  motor  sphere  by  increased  muscular  activity, 
varying  from  busy  occupation  with  nothing  to  gesticulating,  grimacing, 
and  dancing,  and  to  the  wildest  and  most  violent  motor  excitement. 

Primary  exaltation  frequently  gives  rise  to  delusions  of  a  grandiose 
character,  though  these  are  unstable  and  fleeting,  corresponding  to  the 
rapidity  of  change  in  the  contents  of  consciousness.  But  the  feeling 
of  well-being  and  of  egotism  which  makes  up  the  fundamental  mood 
of  the  exalted  patient  leads  him  to  be  extremely  impatient  of  any 
restraint  of  his  activities  ;  and,  in  consequence  of  this,  the  reactive  feel- 
ing of  aggressive  anger  and  fury  is  easily  aroused,  leading  to  acts  of 
violence  and  destruction. 

Irritability. — Irritability  is  a  condition  which  has  to  do  chiefly  with 
the  affects  of  anger  and  rage.  While  observed  in  association  with 
exaltation,  as  just  noted,  and  among  the  prodromata  of  various  insani- 
ties, it  is  particularly  characteristic  as  a  primary  emotional  state  of 
congenital  and  acquired  mental  weakness,  neurasthenic  insanity,  and  the 
epileptic  psychoses.  In  the  latter  it  not  infrequently  becomes  a  true 
furor  epilepticus.  Irritability  is  occasionally  noted  in  the  convalescence 
from  acute  insanities,  sometimes  conjoined  with  a  peculiar  tearfulness, 
a  lacrymose  irritability.  While  most  of  the  affects  of  both  depres- 
sion and  exaltation  are  concerned  with  the  ego,  the  affect  of  anger 
differs  markedly  from  these  in  that  it  has  to  do  with  persons  or  objects 
outside  of  one's  self.  At  the  same  time  anger  is  a  depressed  emotion, 
but  with  certain  peculiarities.  In  its  influence  upon  the  flow  of  ideas 
and  upon  action  it  first  retards  or  inhibits,  but  finally,  by  an  accumula- 
tion of  stimuli,  induces  a  sudden  motor  explosion,  which  may  vary  from 
simple  aggressiveness  to  the  most  uncontrollable  fury.  Abbreviation 
of  the  usual  play  of  motives  is  characteristic  of  the  motor  explosions 
of  anger  and  fury.  The  sensory  stimulus  is  carried  directly  into  the 
motor  areas,  without  the  intervention  of  ideas  or  inhibitions,  which 
accounts  for  the  frequent  occurrence  of  outbreaks  of  violence  and 
destructiveness,  followed  by  complete  or  partial  amnesia  as  to  the  acts 
perpetrated. 

Diminution  or  cessation  of  sensory  and  intellectual  emotional  tone 
gives  rise  to  the  condition  known  as  partial  or  general  apathy.  A 
general  apathy  is  frequently  observed  in  neurasthenic  insanity  and  in 
stuporous  states,  but  it  is  more  common  in  certain  cases  of  melancholia. 
Such  patients  will  complain,  paradoxically  as  it  may  seem,  of  a  painful 
feeling  of  having  lost  all  feeling.  They  say  that  they  feel  no  affection 
for  their  children,  no  hope  of  getting  well,  no  pleasure  in  anything,  no 
grief  at   the   loss   of  friends,  that  their   hearts    are    turned  to    stone. 


660  MENTAL  DISEASES. 

Sometimes  ordinary  sensory  feeling  seems  absent  also,  and  they  say 
they  can  feel  neither  heat  nor  cold,  nor  the  pain  of  a  cut  or  injury. 
One  must  distinguish  between  an  apparent  apathy  and  a  want  of  atten- 
tion consequent  upon  self-centering  of  the  thoughts  on  strong  delusions 
and  hallucinations. 

Partial  apathy  or  limited  defects  of  the  emotions,  as  well  as  of 
special  and  ordinary  sensation,  are  frequently  encountered  in  various 
grades  of  congenital  idiocy  and  acquired  mental  weakness.  Defects  of 
the  higher  forms  of  intellectual  sensory  tone,  the  ethical  feelings,  which 
we  meet  with  in  some  of  these  cases,  constitute  the  so-called  moral  in- 
sanity. 

In  certain  psychoses  a  general  apathy  may  be  so  great  and  the  hori- 
zon of  intellectual  processes  so  narrowed  that  the  condition  amounts  to 
a  pseudodementia  (Magnan),  though  there  is  truly  no  actual  defect  of 
intelligence,  the  mental  functions  being  merely  temporarily  inhibited  or 
suspended. 

A  peculiar  mutability  or  lability  of  affects  is  not  an  infrequent  phe- 
nomenon in  insanity.  Laughing  and  crying  at  the  same  time  is  not  a 
rarity  in  persons  who  are  not  insane,  being  the  result  of  the  com- 
mingling of  pleasant  and  distressing  ideas  present  at  the  same  moment 
in  consciousness.  The  emotional  pendulum  swings  quickly  from  one 
extreme  to  the  other.  Such  disequilibration  is  particularly  character- 
istic of  hysteria,  and  is  notable  in  the  hysterical  psychoses.  But  irri- 
tability and  rapid  alternation  of  cheerful  and  pathetic  affects  are  also 
encountered  in  the  most  various  psychoses.  The  chronic  melancholiac 
with  his  sad  face  and  automatically  repeating  his  set  phrase,  "  I  am 
going  to  be  killed,"  may  laugh  out  suddenly  at  a  funny  incident  and 
immediately  relapse  into  his  habitual  mental  attitude.  In  the  same 
manner  the  paranoiac  may  forget  momentarily  his  persecutory  delusion. 
In  general  paresis  this  swinging  from  one  emotion  to  the  other  in  the 
most  rapid  manner  is  extremely  characteristic.  Mutability  of  affects  is 
indeed  most  common  in  combination  with  conditions  of  intellectual  de- 
fect or  mental  weakness. 


DISORDERS  OF  THE  IDEA-ASSOCIATIONS. 

An  idea-association  is  a  psychological  series,  beginning  with  a  stim- 
ulus and  ending  with  a  movement,  between  which  may  be  one  or  two 
or  more  memory-pictures,  some  coming  into  consciousness,  others  re- 
maining latent,  but  all  associated  by  the  nerve-fibers  running  between 
the  ganglion-cells  of  the  cortex  in  which  are  deposited  the  sensory 
impressions.  The  selection  and  serial  course  of  ideas  in  the  stream  of 
thought  are  determined  by  fixed  laws.  One  of  these  is  the  law  of  simi- 
larity-association— i.  e.,  a  sensation  induces  an  idea  (seeing  a  flower  gives 
the  idea  of  a  flower)  and  another  latent  idea  is  aroused  by  this  (a  rose) 
because  the  second  memory-picture  has  marked  similarity  to  the  first 
idea — the  rose  is  remembered  or  recognized.  Every  recognition  contains 
a  judgment,  since  a  newr  sensation  is  seen  to  be  like  a  former  sensation. 


GENERAL  SYMPTOMATOLOGY  OF  INSANITY.  661 

Another  law  is  that  of  simultaneity  of  reception — i.  e.,  memory-pic- 
tures are  associated  when  their  sensory  stimuli  have  been  received  at  the 
same  time.  For  example,  the  sight  of  a  friend  recall.-  the  city,  the 
street,  the  house  where  one  first  saw  him,  and  many  others  in  a  highly 
complex  series  of  associations.  Not  all  of  these,  however,  will  arise  at 
sight  of  him.  Perhaps  it  may  be  one  or  two,  perhaps  others;  so  that 
another  factor  arises — viz.,  the  degree  of  associative  relationship.  Still 
another  factor  is  the  feeling  (the  intellectual  sensory  tone,  the  affect) 
combined  with  each  of  the  memory-pictures.  Those  memory-pictures 
will  rise  soonest  into  consciousness  which  are  combined  with  the  live- 
liest emotions,  agreeable  or  disagreeable,  pleasant  or  painful.  Ideas 
with  strong  affects  have  a  greater  chance  in  the  conflict  of  ideas  to  rise 
up  from  their  latency  into  consciousness.  Still  another  feature  of  this 
scheme  is  that  the  latent  ideas  with  their  numerous  associations  influ- 
ence one  another  reciprocally,  some  to  excite  and  some  to  suppress  or 
inhibit.  While  simpler  ideas  are  arranged  in  a  sort  of  serial  association 
one  after  the  other,  on  a  higher  plane  the  successive  memory-pictures 
are  bound  together  into  judgments  and  conclusions.  Ziehen  cites  the 
example  of  the  simple  judgment,  "  The  rose  is  beautiful,"  in  which  we 
have  not  these  ideas  discreetly  ranged  one  after  the  other,  but  the  ideas 
"  rose,"  "  is,"  and  "  beautiful "  stand  in  a  thorough  relation  to  one 
another.  This  form  of  idea-association  is  designated  as  a  judgment-asso- 
ciation. 

The  normal  stream  of  ideas,  or  idea-association,  has  a  definite  swift- 
ness which  varies  in  different  individuals  and  in  the  same  individual  at 
different  times.  In  psychopathology  we  learn  that  agreeable  or  pleasant 
affects  hasten  and  disagreeable  or  unpleasant  affects  retard  the  flow  of 
thoughts. 

The  pathological  disorders  of  the  idea-association  are  to  be  classified 
as  follows  : 

1.  Disorders  of  memory. 

2.  Disorders  of  attention. 

3.  Accelerated  flow  of  ideas. 

4.  Diminished  flow  of  ideas. 

5.  Disturbance  of  the  connections  between  the  ideas  of  the  idea- 
association  (incoherence). 

6.  Falsification  of  the  judgment-associations  (delusions  and  impera- 
tive ideas). 

7.  Defective  judgment-associations  (weakness  of  judgment). 
Disorders  of  Memory. — Recollection  according  to  the  principle  of 

similarity-association  is  the  calling  up  (by  a  sensation)  of  a  memory- 
picture  of  earlier,  similar,  or  identical  sensations. 

Recollection  is  disordered  or  destroyed  by  loss  of  the  necessary 
memory-pictures,  by  any  general  marked  retardation  of  cortical  associa- 
tions, and  by  dissociation  of  the  idea-association. 

Dissociation  is  equivalent  to  incoherence,  and  when  a  general  inco- 
herence exists,  disorder  of  recollection  is  the  rule.  The  patient  then 
confounds  persons  and  objects,  and  often  loses  the  ideas  of  place  and 
time   (a   condition  for  which   unorientation   is   the    best  name).     The 


662  MENTAL  DISEASES. 

peculiar  paramnesia  observed  in  alcoholic  psychoses,  especially  in  the 
delirium  accompanying  alcoholic  neuritis,  is  a  striking  example  of  this 
loss  of  orientation.  The  mistaking  or  confounding  of  persons  and 
things  depends  upon  illusions,  delusions,  incoherence  of  ideas,  lack  of 
distinctness  of  the  requisite  memory-pictures,  or,  finally,  upon  voluntary 
caprices  of  the  patient.  In  alcoholic  paranoia  and  epileptic  insanities, 
and  sometimes  in  other  psychoses,  we  encounter  the  so-called  "  halluci- 
nations of  memory  " — a  bad  term  for  the  phenomenon  experienced  some- 
times by  normal  individuals,  of  having  seen  this  or  that  thing,  or  of 
having  been  in  the  same  place  before,  although  in  fact  the  object  and 
place  are  absolutely  new. 

Disorders  of  Attention. — Condillac  stated  that  if  amid  a  multi- 
tude of  sensations  there  is  one  which  predominates  by  its  intensity,  it 
is  thereby  transformed  into  attention.  Ribot  *  regards  spontaneous 
attention  as  always  caused  by  emotional  states.  The  writer  believes, 
with  Ziehen,  that  attention  is  never  voluntary,  but  always  spontaneous  ; 
that  it  is  the  awakening  of  one  idea  from  the  impressions  of  the  in- 
numerable sensations  impinging  on  our  sensory  surfaces.  Such  atten- 
tion depends  upon  several  factors.  One  is  intensity.  Another  is  cor- 
respondence of  the  received  sensation  with  some  latent  memory-picture. 
A  third  factor  is  the  affective  quality  or  sensory  tone  of  the  sensation. 
A  fourth  factor  is  the  combination  of  latent  ideas. 

The  disorders  of  attention  are  morbid  diminution  and  morbid  in- 
crease. The  former  is  extreme  in  idiots,  and  noteworthy  in  patients 
dominated  by  strong  hallucinations  or  overpowering  delusions.  By 
pathological  increase  of  attention  is  meant  the  crowding  of  numerous 
sensations  and  ideas  into  consciousness,  such  as  is  observed,  for  instance, 
in  maniacal  states. 

Accelerated  Flow  of  Ideas. — In  the  highest  degree  of  pathological 
increase  in  the  stream  of  thought  we  observe  not  only  a  rapid  concate- 
nation of  the  associated  ideas,  but  their  swift  transfer  to  the  cortical 
motor  areas,  so  that  gesticulation,  logorrhea,  and  motor  agitation  become 
strikingly  prominent.  It  is  an  ideomotor  excitement.  It  may  be  so 
severe  as  to  present  a  secondary  incoherence.  In  moderate  degrees  of 
acceleration  the  words  spoken  by  the  patient  may,  by  their  sound,  arouse 
associations,  so  that  we  observe  in  the  speech  of  the  patient  a  tendency 
to  riming,  assonances,  and  verbigeration.  The  almost  constant  com- 
bination of  augmented  flow  of  thought  with  an  exalted  and  cheerful 
mood  is  interesting  and,  at  the  same  time,  difficult  to  explain.  Some 
believe  that  the  exaltation  is  due  to  the  patient's  feeling  of  great  facility 
and  fecundity  of  thought.  Others,  again,  consider  the  exaltation  as  the 
primary  phenomenon,  and  that,  as  in  normal  individuals,  the  exal- 
tation induces  the  free  play  of  ideas.  But  it  is  probable  that  the  cheer- 
ful mood  and  accelerated  flight  of  ideas  are  simultaneous  manifestations 
of  the  morbid  process. 

Diminished  Flow  of  Ideas. — In  this  symptom  we  have  features 
quite  opposite  to  those  manifested  in   ideomotor  excitement.      In  the 

1  "  The  Psychology  of  Attention." 


G  EN  Kit  A  L  8  YMPTOMA  TO  LOG  Y  OF  INS  A  NITY.  663 

place  of  increased  we  have  diminished  attention  to  the  sensory  stimulus, 
and  retarded  transfer  of  the  awakened  idea-associations  to  the  motor 
areas  (motor  inhibition).  In  any  noteworthy  inhibition  of  the  How  of 
thought  we  observe  also  difficult  and  retarded  recollection  and  more  or 
less  complete  cessation  of  all  voluntary  movement.  Speech  becomes 
slow,  the  patient  seeking  laboriously  for  words,  and  these  are  simply 
whispered,  not  spoken  aloud.  In  severe  degrees  only  slight  move- 
ments of  the  lips  are  made,  or  complete  mutism  is  presented.  Sunn- 
times  a  word  or  phrase  will  be  repeated  monotonously  over  and  over  ;  a 
single  motion  of  the  arm  or  body  may  be  reiterated  for  hour.-  (stereotyped 
movements).  The  general  musculature  of  the  body  may  be  completely 
relaxed  and  flaccid  (motor-inhibition  with  resolution)  or  in  a  state  of 
tension  (catatonic  inhibition),  or  in  the  condition  known  as  flearibilitas 
cerea.  The  condition  designated  as  stupor  comprises  three  cardinal 
symptoms — viz.,  diminished  attention,  thought-inhibition,  and  motor- 
inhibition.  Stupor  may  be  primary  or  secondary.  When  secondary,  it 
is  ordinarily  induced  by  hallucinations  of  ecstatic,  dreadful,  or  impera- 
tive nature.  Stupor  from  ecstatic  hallucinations  is  frequent  in  hysteria 
and  epilepsy,  and  from  dreadful  hallucinations  in  melancholia  (catatonic 
syndrome).     Primary  stupor  is  another  name  for  primary  dementia. 

Depression  with  thought-inhibition  is  common,  and  among  the  de- 
pressed affects  associated  with  it  we  observe  most  frequently  anxiety. 
According  to  the  motor  symptoms  prominent  in  such  cases,  such  as 
flaccidity  (or  resolution),  catatonic  rigidity,  and  restlessness,  we  dis- 
tinguish three  types — viz.,  melancholia  passiva,  melancholia  attonita, 
and  melancholia  agitata.  The  usual  motor  inhibition  is  concealed  in 
melancholia  agitata  by  the  expression  movements  of  anguish,  such  as 
wringing  the  hands  ;  picking  the  fingers,  face,  or  scalp  ;  restless  moving 
to  and  fro,  anteroposterior  or  lateral  oscillations  of  the  body,  and  the 
like. 

In  the  diagnosis  of  thought-inhibition  we  must  be  careful  to  distin- 
guish, in  the  first  place,  actual  defects  of  intelligence  or  conditions  of 
dementia.  Then  we  must  distinguish  the  primary  form  without  affects 
and  with  affects,  and  the  form  secondary  to  hallucinations  and  delusions. 
Some  of  the  diagnostic  criteria  are  : 

Dementia  and  idiocy  are  stationary  or  progressive  conditions,  while, 
on  the  other  hand,  in  thought-inhibition  there  are  transitory  variations — 
intervals  of  diminished  inhibition. 

Thought-inhibition  is  almost  always  combined  with  motor-inhibition, 
while  this  latter  symptom  is  not  observed  in  defects  of  intelligence. 

The  judgment-associations  in  defective  intelligence  are  also  defective, 
and  wrong  answers  are  often  given  to  questions.  This  is  not  true  of 
states  of  thought-inhibition,  where  correct  answers  are  generally  made, 
if  made  at  all. 

Incoherence. — Incoherence  is  a  dissociation  of  serially  related 
ideas.  Such  dissociation  may  involve  also  the  sensations  which  arouse 
a  series  of  ideas  and  the  motor  sequence  of  a  series  of  ideas.  In  a 
complete  general  incoherence,  then,  the  patient  recognizes  neither  per- 
sons nor  objects,  calls  everything  by  its  wrong  name  (pseudoparaphrasia), 


664  MENTAL  DISEASES. 

uses  everything  wrongly  (pseudo-apraxia),  answers  questions  with  abso- 
lute irrelevancy,  and  shows  even  incoordination  and  pseudo-ataxia  in 
his  movements.  When  the  incoherence  is  marked  in  the  sensory  percep- 
tions, we  speak  of  lack  of  orientation  ;  it  was  formerly  termed  a  disorder 
of  self-consciousness.  When  the  motor  incoordination  is  extreme,  it 
may  amount  to  veritable  jactitation  and  pseudochorea.  Incoherence  is 
most  remarkable,  however,  in  the  speech,  writing,  and  mimetic  expres- 
sion of  the  patient.  The  gestures  and  facial  movements  have  no  rela- 
tion to  the  contents  of  consciousness  ;  laughter  may  accompany  dreadful 
hallucinations  and  a  tearful  countenance  some  jocose  idea.  As  regards 
speech,  if  the  incoherence  is  of  mild  degree,  only  the  sentences  are 
misplaced ;  if  of  severe  degree,  the  very  words  in  the  sentence  are 
jumbled  together,  and  we  observe  the  phenomenon  of  verbigeration 
and  the  manufacture  of  new  words.  The  handwriting  of  the  patient 
may  present  the  same  incoherence  as  the  speech.  The  term  confusional 
insanity  has  been  used  to  describe  the  form  in  which  the  symptoms  are 
want  of  orientation,  incoherence  of  ideas,  and  motor  incoherence.  In- 
coherence may  be  primary  or  secondary,  generally  the  latter.  As  a 
primary  phenomenon,  it  is  the  cardinal  symptom  of  the  incoherent  form 
of  paranoia.  Secondary  incoherence  is  due  to  extreme  rapidity  of  the 
stream  of  ideas,  to  accumulation  of  rapidly  changing  delusions  and  hal- 
lucinations, to  strong  depressing  affects,  and  finally  to  actual  defect  of 
intelligence.  It  is  often  difficult  to  distinguish  primary  from  secondary 
incoherence,  and  far  from  easy  to  differentiate  the  causes  of  the  latter. 

Delusions  and  Imperative  Ideas. — Ideas  are  associated  with  judg- 
ments as  to  similarity,  simultaneity,  properties  of  objects,  etc.,  and  such 
judgment  may  be  correct  or  erroneous  in  normal  individuals,  according 
to  the  weakness  or  strength  of  judgment,  and  according  to  the  degree 
of  correspondence  between  the  sensory  perceptions  and  the  objects  or 
events  of  the  external  world.  The  normal  mind,  however,  generally 
corrects  its  errors  of  judgment  by  repeated  experience  and  better  edu- 
cation— a  physiological  process.  The  pathological  errors  of  judgment 
are  the  delusions  of  the  insane.  These  delusions  are  usually  judgments 
founded  upon  incorrect  sensory  impressions,  such  as  illusions  and  hallu- 
cinations. They  are  rarely  corrected  by  experience,  as  is  the  case  with 
physiological  error.  But  there  are  many  cases  in  which  a  definite 
boundary-line  can  not  be  drawn  between  the  delusions  of  the  sane  and 
those  of  the  insane,  as,  for  instance,  in  the  delusions  of  the  superstitious 
and  of  spiritualists. 

The  delusion  is  the  most  frequent  form  of  pathological  error  of 
judgment,  but  the  imperative  idea  is  also  a  pathological  error  of  judg- 
ment, though  less  commonly  met  with.  Delusions  are  seldom  influenced 
by,  or,  in  fact,  associated  with,  attempts  at  correction  by  the  judgment ; 
whereas  imperative  ideas  are  usually  recognized  as  morbid  by  the  patient, 
but  force  themselves  into  consciousness  despite  the  efforts  of  the  judg- 
ment to  dislodge  them. 

A  delusion  may  arise  in  the  mind  as  a  primary  idea  without  an 
incorrect  sensory  basis,  in  the  same  way  as  an  imperative  idea.  It  may 
be  a  logical  deduction  from  other  delusions,  or,  as  already  stated,  be  the 


GENERAL  SYMPTOMATOLOGY  OF  INSANITY.  665 

product  of  illusions  or  hallucinations.  It  may  be  the  resull  of  a  dream 
carried  over  by  weakened  judgment  into  the  waking  life.  It  may 
develop,  as  in  melancholia  or  mania,  from  the  attempts  of  a  patient   to 

explain  the  origin  of  his  depression  or  exaltation.  Tims,  the  melan- 
choliac  believes  that  his  suffering  must  be  due  to  his  bad  conscience,  to 
some  sin  that  he  has  committed,  to  some  serious  disease  of  his  viscera, 
and  the  like.  The  patient  with  exaltation  of  his  emotional  life  develops 
expansive  ideas  as  to  his  strength,  beauty,  intellect,  wealth,  position,  and 
so  on.  The  character  of  delusions  developed  in  the  insane  is  as  multi- 
form as  are  the  ideas  in  the  mind  of  man. 

Depressive  delusions  are  almost  always  connected  with  the  idea  of 
having  committed  a  sin,  of  having  some  disease  (hypochondriasis),  of 
having  lost  all  property,  or  of  persecution.  Contrasted  or  antagonize 
delusions  of  grandeur  are  sometimes  observed  at  the  same  time  in  con- 
nection with  depressive  delusions.  Thus,  one  patient,  while  weeping  and 
wringing  her  hands,  told  me  she  was  the  queen  of  the  world,  but  was 
unable  to  do  her  duty  because  she  did  not  know  all  languages.  Ziehen 
tells  of  a  patient  who  said,  "  I  was  the  Holy  Ghost.  Had  I  used  my 
omnipotence,  we  would  all  be  happy  now.  But  I  am  cursed.  I  have 
killed  the  Holy  Ghost.  The  whole  world  is  in  misery  and  dread 
through  me."  Hypochondriacal  delusions  generally  arise  from  disorders 
of  common  or  organic  sensibility,  cenesthetic  sensory  impressions, 
though  they  also  develop  from  attempts  at  explanation  of  a  depressed 
mood  and  from  hallucinations.  The  patient  is  certain  he  has  cancer, 
consumption,  syphilis,  brain-softening  ;  that  he  is  impotent ;  that  his 
alimentary  canal  is  closed  up  ;  that  his  brain  has  been  removed  ;  that  his 
viscera  and  tissues  have  been  metamorphosed  into  stone,  glass,  wood, 
and  the  like.  A  peculiar  form  of  hypochondriacal  delusion  is  the  so- 
called  micromania  not  infrequently  observed  in  depressed  periods  of 
general  paresis.  Patients  with  micromania  assert  that  whole  viscera 
have  been  removed  from  their  bodies,  that  their  blood  is  all  gone,  and 
that  they  have  been  reduced  in  size.  Thus,  one  patient  told  me  she  was 
so  small  she  could  be  put  into  a  pill-box.  Another  said  his  intestines 
were  absolutely  closed  up  and  he  should  have  to  be  cut  open  to  have 
the  obstacles  removed.  The  delusion  of  pregnancy  arises  from  perver- 
sion of  abdominal  sensory  impressions. 

The  delusion  of  persecution  differs  from  the  other  depressive  de- 
lusions in  that  it  has  to  do  with  the  enmity  of  other  persons  in  the 
environment,  whereas  these  are  concerned  altogether  with  the  ego  of  the 
patient,  his  own  conscience,  his  own  mind,  his  own  body.  The  delusion 
of  persecution  is  important  to  the  general  practitioner,  because  it  is  very 
common,  because  it  is  met  with  so  often  outside  of  institutions,  because 
it  not  infrequently  leads  to  assaults  and  murder,  and  because  its  signifi- 
cance in  prognosis  varies  with  the  species  of  mental  disorder  in  which  it 
is  encountered.  It  is  observed,  for  instance,  in  toxic  insanities  which 
are  curable  ;  in  melancholia,  in  which  cure  is  difficult ;  and  in  paranoia, 
which  is  incurable.  The  most  common  origin  of  the  delusion  of  perse- 
cution is  from  hallucinations.  The  patient  hears  mocking  or  threaten- 
ing voices,  he  tastes  poisons  in  his  food,  he  sees  lowering  looks  and 


666  MENTAL   DISEASES. 

menacing  gestures,  he  feels  singular  sensations  in  his  body  which  must 
be  due  to  irritant  poisons  thrown  upon  him  or  to  electricity,  or  he  smells 
noxious  gases.  The  delusion  of  persecution  may  grow  out  of  a  series 
of  hypochondriacal  delusions,  in  the  attempt  of  the  patient  to  explain 
the  origin  of  his  miseries.  It  may  arise  also  from  the  delusion  of 
having  committed  a  sin  or  crime,  the  patient  imagining  that  every  one 
hates  him  and  follows  him  to  punish  him.  Sometimes  these  persecutory 
delusions  are  referred  to  the  influence  of  unseen  agencies — hypnotism, 
telepathy,  electricity,  magnetism.  Sometimes  they  have  to  do  with  the 
property  or  social  position  of  the  patient ;  he  believes  his  belongings  are 
being  stolen,  or  his  character  maligned.  Sometimes  erotic  ideas  are 
bound  up  with  persecutory  ideas ;  a  woman  believes  herself  secretly 
cohabited  with  at  night,  or  even  by  day,  through  occult  means  ;  a  man 
thinks  he  is  made  impotent,  that  his  seminal  fluid  is  being  drawn  off. 
Obviously,  these  latter  ideas  often  rest  upon  perverted  sensory  impres- 
sions received  from  the  sexual  organs.  In  seeking  to  discover  the 
origin  of  the  persecution,  the  patient  often  at  first  settles  upon  some  one 
definite  individual,  but  later,  when  he  finds  the  methods  of  persecution 
innumerable  and  that  his  enemies  follow  him  wherever  he  goes,  he  can 
not  believe  that  any  one  person  could  do  so  much  ;  he  reaches  the  con- 
clusion that  it  must  be  a  wide-spread  conspiracy,  such  as  could  be  carried 
out  only  by  some  large  affiliation  of  persons,  such  as  societies  of  Free- 
masons, anarchists,  Jesuits,  lawyers,  and  police.  The  delusion  of  per- 
secution occasionally  develops  from  a  delusion  of  grandeur ;  the  patient 
believes  he  is  persecuted  because  of  his  wealth  or  exalted  position. 
More  often,  however,  the  contrary  is  the  case,  the  patient  coming  to 
believe  himself  some  extraordinary  personage  because  of  the  persecu- 
tions to  which  he  is  subjected. 

Another  interesting  form  of  depressed  delusion  is  that  of  negation 
(delire  de  negation  generalize),  which  has  its  origin  usually  from  an  idea 
of  having  sinned.  The  patient  thinks  he  must  be  the  devil  himself,  his 
sin  is  so  great ;  consequently  he  can  never  die,  he  must  suffer  forever  ; 
then,  with  the  growing  idea  of  the  enormity  of  his  sin,  he  comes  to 
believe  that  God  and  mankind  and  the  world  exist  no  more. 

Delusions  of  grandeur  vary  from  simple,  expansive  ideas  of  the 
patient's  importance,  prerogatives,  and  powers,  to  delusions  of  being 
inventors,  geniuses,  prophets,  reformers,  titled  and  royal  personages,  and 
even  Christ,  God,  and  the  mother  of  God.  Besides  his  own  person- 
ality, his  environment  maybe  vested  with  grandiose  qualities — his  room 
a  palace,  his  straw  hat  a  crown,  pebbles  diamonds,  his  children  prin- 
cesses, and  so  on.  A  peculiarity  of  the  ideas  of  grandeur  observed  in 
general  paresis,  which  is  quite  pathognomonic,  is  their  enormity  or, 
rather,  monstrosity.  It  is  not  enough  to  be  wealthy,  but  sextillions  of 
planets  can  not  hold  the  gold  and  jewels.  It  is  not  sufficient  to  have  a 
dozen  children,  but  billions  of  children  are  given  birth  to  nightly  by  his 
innumerable  wives.  He  will  make  a  new  Niagara,  by  bringing  the 
Pacific  Ocean  over  the  Andes.  Should  sexual  ideas  prevail,  he  may 
say  that  his  penis  is  a  mile  long,  and  his  testicles  are  huge  diamonds. 
He  will  move  the  asylum  across  the  United  States  on  a  road  of  solid 


GENERAL  SYMPTOMATOLOGY  OF  INSANITY.  667 

gold.     Such  enormities  betoken  great  weakening   of  the   intellect    and 
judgment. 

Primary  delusions  conduce  more  to  iixity  than  delusions  secondary 
to  hallucinations.  The  latter,  depending  as  they  do  upon  the  stability 
or  instability  of  the  morbid  sensory  impressions,  change  with  these. 
When  delusions  become  fixed,  they  tend  to  crystallize  or  become  sys- 
tematized. Systematization  consists  of  combining  with  the  fixed  idea 
complementary  delusions  in  a  more  or  less  logical  order  or  of  the  fan- 
tastic elaboration  of  the  original  delusion.  The  degree  of  organization 
and  perfection  of  the  delusional  structure  will  depend  upon  fancy, 
logical  faculty,  social  position,  and  education  of  the  patient.  The  most 
common  form  of  systematization  is  in  the  development  of  secondary 
grandiose  ideas  upon  a  persecutory  basis.  But  almost  any  of  the  de- 
pressed and  exalted  delusions  previously  described  may  become  fixed, 
systematized,  and  permanent  through  the  life  of  the  patient. 

Delusions  may  have  a  retroactive  effect  in  awakening  sensory  im- 
pressions, instead  of  being  aroused  by  them — that  is,  may  induce  illu- 
sions and  hallucinations.  For  example,  the  persecuted  patient  perceives 
voices,  odors,  tastes,  pains,  etc.,  often  because  of  his  mind  being  in  a 
state  of  expectant  attention. 

Imperative  ideas  force  themselves  into  consciousness  in  spite  of 
the  efforts  of  the  patient — who  recognizes  their  morbid  character — to 
correct  them.  They  are  accompanied,  almost  without  exception,  by  a 
depressive  affect,  a  painful  sensory  tone.  They  are  extremely  common 
in  neurasthenia.  Senseless  phrases  or  doggerel  repeat  themselves  over 
and  over  in  the  patient's  mind.  The  many  varieties  of  phobia  are 
familiar  examples  of  imperative  ideas  in  neurasthenics  (agoraphobia,, 
claustrophobia,  mysophobia,  etc.).  Imperative  ideas  are  also  observed 
in  melancholia  and  in  a  form  of  insanity  wThich  has  been  designated  as 
insanity  from  imperative  ideas.  In  very  rare  instances  they  are  en- 
countered in  early  stages  of  general  paresis.  They  always  develop  on 
the  basis  of  a  congenital  or  acquired  neuropathic  or  psychopathic  con- 
stitution, and  are  apt  to  become  obstinate  features  in  the  mental  organi- 
zation. Almost  every  imperative  idea  has  its  inception  in  some  sort  of 
sensory  impression,  and  the  idea  may  lead  to  compulsory  actions  on  the 
part  of  the  patient.  But  between  the  imperative  idea  and  the  conse- 
quent action  there  is  generally  a  play  of  judgment,  a  faltering  between 
the  imperative  idea  and  antagonistic  or  inhibiting  concepts.  For 
instance,  the  patient  feels  a  compulsion  to  lock  a  door  which  he  feels 
sure  he  has  already  locked.  After  an  inward  debate  as  to  whether  he 
should  go  back  and  assure  himself  that  it  is  locked,  which  may  last 
many  minutes  or  longer,  he  goes  to  lock  it,  and  on  leaving  the  door 
again  the  imperative  idea  arises  that  it  is  not  locked.  The  same  play 
of  antithetic  ideas  may  occur  in  reference  to  anything — the  addressing 
of  a  letter,  the  return  of  a  book  to  a  shelf,  acts  of  dressing  and  un- 
dressing, the  crossing  of  a  street,  etc.  In  some  cases  the  imperative 
idea  takes  the  form  of  compulsion  to  jump  from  a  height,  to  laugh  in 
unseemly  places ;  or  obscene  and  sacrilegious  words,  sentences,  and  fan- 
cies may  thrust  themselves   obstinately   into  the  consciousness.      For 


668  MENTAL   DISEASES. 

example,  a  gentleman,  and  a  good  Christian,  came  to  me  recently  over- 
whelmed with  the  sacrilegious  conceptions  which  first  came  to  him  at  a 
church-service  a  week  or  two  before — ideas  of  cohabitation  with  the 
Virgin  Mary  and  filthy  expressions  in  relation  to  Christ.  A  lady  con- 
sulted me  about  a  morbid  fear  that  she  had  of  canary  birds.  She 
could  not  enter  a  house  or  hotel  in  which  there  was  a  canary  bird, 
because  she  was  afraid  that  bird-seed  might  get  about  and  in  some  way 
get  into  her  mouth,  be  swallowed,  and  grow  in  her  stomach.  The  con- 
tents of  these  imperative  concepts  are  as  varied  as  those  of  delusions, 
though  they  are  almost,  without  exception,  trivial  or  unpleasant. 

Folie  du  doute  is  a  form  of  mental  disorder  in  which  compulsory 
ideas  assert  themselves  in  the  form  of  questions,  religious,  metaphysi- 
cal, or  in  regard  to  the  most  trivial  things  or  events  (Shall  I  do  this  or 
that  ?  Why  is  the  table  round  ?  Why  is  the  chair  by  the  bed  ?  Why 
are  two  and  two  four  ?).  One  young  lady  is  so  incapable  of  deciding 
any  question  that  comes  up  in  her  mind  that  she  does  not  know 
whether  she  ought  to  dress  or  undress,  go  to  bed,  eat,  sleep,  pray,  or 
consult  a  doctor.  Every  trivial  question  of  the  day  requires  hours 
of  painful  and  agonizing  debate  in  her  mind. 

Imperative  ideas  frequently  impel  to  compulsory  speech  and  actions. 
Coprolalia  is  a  not  uncommon  form  of  imperative  speech  in  which  the 
patient  is  impelled  to  the  utterance  of  obscene  words.  Quite  analo- 
gously the  patient  may  be  made  to  make  grimaces,  or  may  develop  the 
so-called  maladie  des  tics. 

Weakness  of  Judgment. — Innumerable  memory-pictures  and 
associated  ideas  take  part  in  the  process  of  comparison  and  decision 
which  we  know  as  judgment.  Hence  any  disorder  of  memory  and  of 
its  associations,  such  as  loss,  defect,  or  perversions  (delusions,  hallucina- 
tions, or  illusions),  must  naturally  influence  the  character  of  the  judg- 
ment. One  of  the  common  conditions  which  impairs  judgment  is, 
therefore,  intellectual  defect,  such  as  congenital  or  acquired  mental 
weakness.  The  criteria  of  idiocy  and  dementia  are  poverty  of  ideas 
and  idea-associations  and  weakness  of  judgment.  When  delusions  or 
imperative  ideas  exist,  the  errors  of  judgment  are  due  to  the  overriding 
and  eclipsing  by  single  ideas  and  idea-associations  of  all  others  which 
would  in  the  normal  mind  give  balance,  control,  and  revision  to  the 
judgment.  Defective  judgment  varies  in  degree  from  a  slight  loss  of 
the  critical  faculty  to  complete  deficiency.  When  the  judgment  is 
markedly  defective,  it  depends  upon  actual  organic  changes  in  the 
brain,  such  as  we  observe  in  idiocy,  terminal  dementia,  senile  dementia, 
and  general  paresis,  and  hence  as  a  symptom  it  is  far  more  ominous 
than  delusions  and  imperative  ideas,  which  usually  rest  upon  a  func- 
tional pathological  basis.  Its  significance,  then,  demands  a  careful 
differentiation  of  this  symptom  from  others  with  which  it  might  be 
confused,  such  as  incoherence  and  thought-inhibition.  In  incoherence 
the  threads,  of  thought  are  constantly  lost.  In  thought-inhibition  there 
are  a  depressive  affect  and  extraordinary  slowness  of  association  with 
correspondingly  tardy  answers,  and,  besides,  there  are  variations  of  depth 
of  inhibition,  so  that  at  times  complicated  answers  and  judgments  are 


GENERAL   SYMPTOMATOLOGY  OF  INSANITY.  669 

readily  given.  In  actual  weakness  pf  judgment  the  judgments  ren- 
dered are  false,  and  the  more  incorrect,  the  more  complicated  the 
questions. 

DISORDERS  OF  ACTIONS. 

The  actions  or  conduct  of  a  patient  depend  directly  and  necessarily 
upon  pathological  elements  in  some  part  of  the  psychological  processes 
— sensation,  memory-pictures,  idea-associations,  and  their  emotional 
affects.     They  may  be  classified,  following  Ziehen,  as — 

1.  Actions  induced  by  sensory  disorders. 

2.  Actions  induced  by  disorders  of  memory. 

3.  Actions  induced  by  disorders  of  the  emotions. 

4.  Actions  induced  by  disorders  of  the  idea-association. 

Actions  Induced  by  Sensory  Disorders. — Hallucinations  and 
illusions  affect  the  conduct  of  a  patient  often  markedly,  and  their  influ- 
ence is  always  greater  than  that  of  normal  sensations.  Their  dominance 
is  the  greater  in  proportion  to  their  number  and  to  the  rapidity  of  their 
accumulation.  Hallucinations  gathered  slowly  in  the  course  of  weeks 
or  months,  while  they  may  not  be  corrected,  are  at  least  subject  to  a 
certain  amount  of  control  by  the  inhibition  of  normal  ideas.  In  the 
most  chronic  forms  of  hallucination  the  voices,  common  sensations,  and 
visions  tend  to  be  ignored  and  to  influence  to  a  very  slight  degree  the 
conduct  of  the  patient.  A  very  important  practical  feature  in  regard  to 
hallucinations  and  their  effects  upon  conduct  is  their  uncertainty.  They 
are  never  to  be  reckoned  with,  and  one  can  never  know  wThat  sudden 
violence  or  destructiveness  may  result  from  new  hallucinations  rising  in 
the  patient's  brain. 

Actions  Induced  by  Defects  of  Memory. — These  are  observed  in 
congenital  or  acquired  weak-mindedness,  where  the  conduct  is  directly 
ordered  by  sensory  impressions,  without  that  intervention  of  the  play 
of  motives  which  we  observe  in  normal  individuals.  They  are  more 
like  the  actions  of  the  lower  animals,  which  may  be  complete  enough  in 
their  way,  but  are  not  motived  by  complicated  abstract  conceptions, 
because  these  are  wanting. 

Actions  Induced  by  Disorders  of  the  Emotions. — As  already 
elsewhere  intimated,  simple  depressed  emotions  are  accompanied  by  a 
general  motor  inhibition,  and  simple  exalted  emotions  by  a  general 
motor  agitation.  But  when  the  depressed  affect  attains  to  the  degree  of 
anxious  dread,  we  may  have  a  restlessness,  a  desire  for  flight,  which  in 
itself  amounts  to  a  motor  agitation.  This  anxious  state  often  leads  to 
suicidal  attempts,  and  even  to  homicidal  assaults,  arson,  and  other  forms 
of  crime  and  violence.  The  whole  nervous  system  seems  to  be  in  such 
a  state  of  tension  that  only  an  explosion  can  give  relief. 

In  apathetic  conditions  action  is  reduced  to  its  minimum. 

Where  the  higher  affects,  which  are  at  the  basis  of  ethical  concepts, 
are  absent  or  lost,  as  in  congenital  or  acquired  states  of  mental  weak- 
ness, crimes  against  person  and  property  are  common. 

In  conditions  of  anger  and  rage  there  is  at  first  a  brief  period  of 


670  MENTAL   DISEASES. 

speechlessness  and  immobility,  followed  by  an  explosion  of  blind  and 
violent  motor  excitement,  in  which  the  most  dangerous  assaults  may  be 
made. 

In  conditions  of  changeability  or  lability  of  the  emotions,  we  ob- 
serve analogous  motor  states — sudden  changes  from  weeping  and  wailing 
to  boisterous  cheerfulness,  and  vice  versa. 

A  study  of  emotional  expression  is  of  particular  diagnostic  value  in 
insanity,  but  the  features  of  such  expression  and  gesticulation  are  so 
well  known  that  they  need  no  detailed  description  here.  Each  mood, 
be  it  simple  depression,  anxious  terror,  excitation,  anger,  apathy,  or 
emotional  lability,  has  its  own  familiar  motor  habiliments. 

Actions  Induced  by  Disorders  of  the  Idea-association  or  Stream 
of  Thought. — Under  this  heading  are  gathered  the  multiform  modes 
of  action  caused  by  increase  in  the  flow  of  ideas,  retardation  of  the 
stream  of  thought,  incoherence,  delusions,  imperative  ideas,  and  weak- 
ness of  judgment. 

In  increased  rapidity  of  the  flow  of  ideas  we  note  motor  agitation 
or  morbid  impulse  to  movement,  varying  from  simple  talkativeness, 
with  active  play  of  expression,  to  loud  garrulity,  grimaces,  gesticula- 
tion, busy  walking  about,  running,  dancing,  and,  in  extreme  degrees,  to 
undressing,  destructiveness  of  clothing,  bedding,  furniture,  and  blind 
throwing  about  of  the  body  in  every  conceivable  way.  This  so-called 
primary  motor  agitation  should  be  distinguished  from  the  motor  agita- 
tion which  is  secondary  to  crowding  hallucinations  (hallucinatory  agita- 
tion) and  to  emotions  like  terror  and  anger  (affective  agitation). 

The  behavior  of  the  movements  in  regard  to  retarded  flow  of  thought 
has  already  been  briefly  alluded  to.  There  is  a  general  motor  inhibition, 
varying  from  simple  slowness  and  difficulty  of  executing  any  movement, 
whether  of  speech  or  other  muscles,  to  a  complete  cessation  of  volun- 
tary movements,  a  stuporous  or  attonitous  condition,  in  which  the 
muscles  may  be  absolutely  at  rest  and  flaccid  or,  on  the  other  hand, 
in  a  condition  of  catatonic  tension.  In  true  catatonic  tension  every 
attempt  at  passive  movement  is  resisted,  but  in  another  form  of  this 
there  is  a  waxy  flexibility  of  the  muscles,  so  that  the  limbs  yield  readily 
to  any  passive  motion,  remaining  in  whatever  position  the  physician 
desires  to  place  them.  Occasionally  one  encounters  in  cases  of  retarded 
idea-associations,  as  an  expression  of  motor  inhibition,  a  tendency  to  the 
repetition  of  some  restricted  voluntary  movement  in  a  rhythmical, 
stereotyped  way  for  days,  weeks,  months  at  a  time.  Such  stereotyped 
motions  may  be  simple  anteroposterior  oscillations,  lateral  oscillations, 
whirling,  walking  to  and  fro  or  in  a  circle,  waving  the  hands  rhythmi- 
cally— forms  of  tics  exceedingly  common  in  idiocy  and  imbecility, 
but  common  enough  in  melancholias  and  terminal  dementias.  The 
repetition  of  stereotyped  or  automatic  phrases  is  analogous  in  character 
to  such  morbid  movements.  Motor  inhibition  is  primary  or  secondary. 
The  primary  form  is  generally  a  simple  resolution  or  flaccidity,  occa- 
sionally a  slight  catatonic  tension  or  flexibilitas  cerea.  Secondary  motor 
inhibition  is  due  to  hallucinations,  delusions,  and  states  of  mental  weak- 
ness. 


GENERAL   SYMPTOMATOLOGY  OF   INSANITY.  671 

Incoherence  of  ideas  leads  to  a  dissociation  also  in  the  motor  ex- 
pressions of  ideas,  parapraxia,  paramimia,  incoordination,  pseudo-ataxia, 
incoherent  agitation,  chorea  magna,  and  jactitation.  Such  motor  agita- 
tion may  be  primary  or  may  be  the  secondary  result  of  innumerable 
clashing  hallucinations  and  delusions,  rapidity  of  the  flight  of  ideas  or 
of  intellectual  defects. 

Grandiose  delusions  exert  their  own  peculiar  influence  on  the 
demeanor  and  speech  of  the  patient,  according  to  the  contents  of  the 
exalted  ideas.  We  observe  the  proud  bearing ;  the  self-sufficient, 
haughty,  or  secret  smile  ;  the  withdrawing  from  others  ;  the  tendency  to 
decoration  of  the  person  ;  the  attempts  to  act  the  parts  of  the  personage 
he  imagines  himself  to  be  ;  the  striking  peculiarities  of  handwriting. 
In  some  instances  delusions  of  grandeur  lead  to  homicidal,  rarely 
suicidal,  attempts  (self-crucifixion  with  the  delusion  of  being  Christ). 
Grandiose  erotic  ideas  sometimes  occasion  masturbation.  Coprophagy 
and  other  filthy  habits  may  depend  upon  grandiose  delusions  as  to 
extraordinary  virtues  of  the  patient's  excretions. 

In  depressed  delusions,  particularly  as  regards  ideas  of  sin  and 
poverty,  we  observe  the  characteristic  melancholy  facial  expression 
and  attitudes.  Attempts  at  suicide  are  frequent,  and  sometimes 
self-mutilation.  Abstention  from  food  is  especially  common  with 
the  delusion  of  poverty,  the  patient  feeling  that  he  can  not  pay  for 
anything. 

Hypochondriacal  ideas  influence  markedly  the  patient's  actions  and 
conduct.  The  hypochondriac  may  neglect  every  duty  in  the  constant 
contemplation  of  his  symptoms.  He  reads  medical  books,  goes  from 
one  physician  to  another,  takes  to  his  bed  perhaps  permanently,  and  so 
on.  The  effects  of  hypochondriasis  on  motor  functions  are  frequently 
remarkable,  leading  sometimes  to  astasia  or  abasia,  or  both  ;  to  hypo- 
chondriacal ataxia,  tremor,  or  convulsive  movements  of  the  extremities. 
These  hypochondriacal  motor  conditions  are  always  the  result  of  a  series 
of  morbid  judgments  on  a  hypochondriacal  basis,  and  are  to  be  distin- 
guished from  similar  hysterical  states  which  have  an  autochthonous  origin 
without  any  antecedent  conscious  reasoning  process. 

The  persecutory  delusions  lead  to  systems  of  self-protection  of  the 
most  varied  kind.  Barricades,  stopping  up  of  cracks  and  keyholes, 
the  wearing  of  peculiar  clothing  (silk,  paper,  etc.,  for  instance,  as  a 
guard  against  electrical  shocks),  avoiding  of  food  and  drink  which  are 
suspected  of  containing  poison,  arming  with  weapons,  frequent  change 
of  servants  or  residence,  and  complaints  to  the  police  or  judicial 
authorities.     Homicide  is  common  in  these  cases. 

Imperative  ideas  lead  to  imperative  movements  and  actions,  and 
generally  in  spite  of  the  well-preserved  consciousness  and  judgment  of 
the  patient.  Such  imperative  actions  are  as  various  in  character  as  the 
imperative  ideas  to  which  they  correspond.1 

Accompanying  Physical  Disorders  in  Insanity. — Among  the 

1  The  foregoing  account  of  the  psychopathology  of  insanity  is  largely  a  presenta- 
tion of  the  views  of  Ziehen,  to  whose  excellent  work  the  author  must  refer  readers  for 
greater  detail. 


672 


MENTAL   DISEASES. 


many  somatic  symptoms  which  may  complicate  or  accompany  psychoses 
are  chiefly  to  be  mentioned  the  following  : 

1.  Motor  disorders. 

2.  Sensory  disorders. 

3.  Reflex  disorders. 

4.  Trophic  disorders. 

5.  Secretory  and  excretory  disorders. 

6.  Temperature  disorders. 

7.  Vascular  disorders. 

Motor  Disorders. — These  may  be  manifested  in  the  form  of  morbid 
movements  or  paralysis.  In  the  first  category  are  assembled  such 
symptoms  as  epilepsy,  convulsions,  chorea,  choreiform  movements, 
tremor,  tics,  ataxia,  masticatory  spasm,  and  the  like.  The  following 
table,  modified  from  Ziehen,  gives  a  general  summary  of  the  paralytic 
symptoms  noted  in  insanity  : 


Form    of 
Paralysis. 

Character. 

Trophic 
Disturbances. 

Spasticity 

or 
Flaccidity. 

Sensory 
Disorders. 

Deep 
Reflexes. 

Hypochon- 
driacal. 

Usually  limited 
to     a    certain 
form  of  move- 
ment. 

No  atrophy. 

Flaccidity. 

None. 

Normal. 

Hysterical. 

Monoplegia, 
hemiplegia,  or 
paraplegia. 

Disuse  atro- 
phy. 

Frequently 
contractures. 

Hemianes- 
thesias, etc. 

Normal     or 
hypertypical. 

Cortical. 

Monoplegia    or 
hemiplegia. 

Disuse  atro- 
phy. 

Rigidity,  con- 
tractures, lo- 
cal spasms. 

Paresthesias, 
occasionally 
anesthesias. 

Exaggerated 
usually. 

Pyramidal 
tract. 

Hemiplegia   or 
paraplegia. 

Disuse  atro- 
phy. 

Spasticity, 
contractures 
frequently. 

Occasionally 
anesthesia, 
hemianop- 
sia, etc. 

Exaggerated. 

Peripheral. 

Multiple  or  sin- 
gle. 

True  atrophy 
with  degen- 
erative   re- 
action. 

Flaccidity. 

Hyperesthes- 
ias, stocking 
and  glove 
areas  of  an- 
esthesias 
often. 

Lost. 

Sensory  Disorders. — Anesthesias  and  hyperesthesias  have  already 
been  mentioned,  but  hyperalgesias  and  paresthesias  of  divers  kinds  are 
encountered  among  the  psychoses,  such  as  headache,  migraine,  neural- 
gias, feeling  of  fullness  in  the  head,  scotomata,  tinnitus  aurium,  and  so 
on.  Neuralgia  is  occasionally  a  cause  of  insanity.  Migraine  is  a  fre- 
quent precursor  of  general  paresis  and  concomitant  of  epilepsy.  Light- 
ning pains  are  noted  in  tabic  types  of  dementia  paralytica.  Neurasthenic 
pains  and  paresthesias  in  the  extremities,  spine,  and  head  are  found  in 


GENERAL  SYMPTOMATOLOGY  OF  INSANITY.  673 

neurasthenic  forms  of  insanity.  Where  hysteria  complicates  a  psychosis, 
there  are  often  observed  the  sensory  disturbances  characteristic  of  thai 

malady. 

Reflex  Disorders. — Changes  in  the  reflexes  are  important  in  hut  a 
few  forms  of  insanity.  In  paralytic  dementia  we  observe  nearly  always 
exaggerated  tendon-reflexes,  hut  in  tabic  types  they  are  lost.     They  are 

lost  also  in  psychoses  complicated  with  multiple  neuritis,  and  frequently 
in  cases  with  diabetes,  and  in  morphinomania.  The  deep  reflexes  are 
exaggerated  in  senile  dementia,  many  acute  affective  insanities,  hysteria, 
epilepsy,  and  in  patients  with  accompanying  multiple  sclerosis.     The 

state  of  the  superficial  reflexes  possesses  little  significance,  except  in  in- 
sanity associated  with  hysteria  and  organic  disorders  of  the  brain,  spinal 
cord,  or  peripheral  nerves. 

The  Argyll-Robertson  pupil  is  met  with  almost  constantly  in  gen- 
eral paresis.  The  pupils  in  all  cases  of  insanity  should  be  examined  as 
to  their  equality,  size,  and  reaction  to  light,  and  in  accommodation. 
Loss  of  reaction  to  light  may  be  observed,  besides,  in  general  paresis,  in 
syphilitic  insanities,  senile  insanity,  and  in  some  alcoholic  cases ;  it 
means  organic  disease  of  the  brain.  In  rare  instances  a  transitory 
rigidity  of  the  pupil  occurs  in  epilepsy  and  morphinomania.  Inequality 
of  pupils  is  very  common  in  organic  and  occasional  in  functional  in- 
sanities. 

Trophic  Disorders. — General  disturbances  of  nutrition,  variations 
in  bodily  weight,  are  commonly  noted,  and  possess  considerable  signifi- 
cance. Thus,  rapid  increase  in  weight  is  characteristic  of  the  progress  of 
an  acute  psychosis  to  terminal  dementia ;  if,  however,  it  accompanies  an 
improvement  in  mental  symptoms,  it  betokens  convalescence.  In  some 
cases  enormous  decrease  in  weight,  in  association  with  pernicious  anemia, 
leads  to  a  fatal  termination.  Certain  forms  of  insanity,  especially 
organic,  notably  paralytic  dementia,  present  a  remarkable  trophic 
disturbance  in  the  bones,  a  fragilitas  ossiuni,  inducing  easy  fracture. 
Decubitus  is  observed  in  bedridden  insane  patients,  particularly  paretics. 

Hematoma  auris,  othematoma,  or  the  "  insane  ear,"  is  a  deformity 
of  the  ear  produced  by  a  hemorrhage  into  the  substance  of  the  auricle,, 
usually  between  the  perichondrium  and  the  cartilage.  It  is  undoubtedly 
traumatic  in  its  origin,  but  there  is  fundamentally  some  change  in  the 
vascular  walls  in  certain  cases  of  chronic  insanity,  rendering  them 
fragile  and  easily  ruptured  by  the  most  trivial  pressure  or  injury. 
Such  effusions  of  blood  do  occur  in  normal  individuals  (athletes  and 
boxers),  but  always  from  severe  trauma.  The  frequency  of  hematoma 
auris  in  general  paralysis,  and  in  many  chronic  forms  of  insanity  is 
only  explicable  on  the  hypothesis  of  some  trophic  change  in  the  vessel- 
walls. 

Secretory  Disorders. — The  secretion  of  tears  is  generally  reduced 
or  absent  in  melancholia. 

The  saliva  may  be  diminished  in  quantity  in  melancholia.     More 

often  in  many  forms  of  insanity  it  is  increased,  the  excessive  secretion 

amounting  sometimes  to  a  sialorrhea.     The  increase  is  due  to   constant 

mastication,  to  illusions  and  hallucinations  of  taste,  and  sometimes  to 

43 


674  MENTAL  DISEASES. 

irritative  stimuli  in  the  secretory  centers.  Drooling  may  give  the  ap- 
pearance of  an  increase  of  salivary  flow,  because  of  relaxation  of  the 
oral  and  buccal  muscles,  or  because  the  secretion  is  not  swallowed. 

Diminution  or  increase  of  hydrochloric  acid  in  the  gastric  juice  is 
noted  in  many  cases  of  insanity,  and  the  quantity  may  be  determined 
by  the  Sjoqvist  method.  Hypochlorhydria  exists  in  common  in  states 
of  congenital  and  acquired  intellectual  defect  and  in  general  paresis. 
Hyperchlorhydria  is  not  infrequently  met  with  in  cardialgic  attacks, 
after  epileptic  seizures,  and  in  catatonic  conditions. 

As  regards  the  urine,  quantitative  and  qualitative  changes  are  very 
common  in  insanity.  These  changes  may  be  the  expression  of  abnormal 
metabolism  in  the  central  nervous  system,  of  abnormal  metabolism  in 
other  parts  of  the  body  induced  by  disease  of  the  central  nervous  sys- 
tem, or  of  vasomotor  changes  in  the  kidneys  brought  about  by  the 
psychoneurosis.  Polyuria  is  observed  in  many  organic  psychoses  and 
in  hysterical  complications.  Oliguria  is  characteristic  of  melancholy 
and  stuporous  conditions.  In  hysterical  insanity  there  is  frequently  an 
alternation  between  oliguria  and  polyuria. 

As  regards  the  qualitative  changes  in  the  urine  of  the  insane,  we 
are  year  by  year  recognizing  more  and  more  the  importance  of  investi- 
gation in  this  direction.  There  is  no  doubt  that  the  deeper  our  re- 
searches go  into  the  chemistry  of  metabolism  and  catabolism,  the 
nearer  do  we  attain  to  a  better  understanding  of  the  mysterious  nutri- 
tional processes  that  have  to  do  with  the  construction  of  the  blood  and 
that  underlie  so  many  psychoses.  Albumin,  peptone,  and  propeptone 
are  found  not  infrequently  in  the  urine  of  cases  of  organic  insanity,  in 
delirium  tremens,  in  epilepsy,  and  in  acute  mania.  Their  presence  is 
often  transitory,  and  unaccompanied  by  renal  disease.  Hyalin  cylinders 
are  also  often  observed  in  severely  excited  conditions. 

Excessive  phosphaturia  is  noteworthy  in  many  cases  of  great  cere- 
bral excitement,  and  after  epileptiform  and  apoplectiform  seizures.  In 
chronic  brain  disorders  the  quantity  of  phosphoric  acid  is  diminished 
below  the  normal. 

The  chlorids  are  lessened  in  quantity  in  melancholia.  They  are 
increased  in  the  early  stages  of  paresis,  but  diminish  with  the  progress 
of  the  disease  to  dementia. 

Sulphates  and  the  aromatic  ethereal  sulphates  (the  latter  being  the 
product  of  destructive  proteid  metabolism)  are  increased  in  febrile  con- 
ditions, and  in  conditions  attended  with  much  tissue-waste. 

Urea  is  also  representative  of  destructive  proteid  metabolism,  and  is 
an  index  of  the  general  nitrogenous  metabolism  of  the  body.  It  is 
increased  in  conditions  associated  with  tissue-waste,  diminished  in  states 
of  malnutrition.  Uric  acid  and  the  urates  have  much  the  same  rela- 
tion. 

Oxaluria  (any  increase  above  the  normal  amount  excreted  in  twenty- 
four  hours — viz.,  T3¥  of  a  grain)  is  observed  in  certain  nervous  and 
mental  disorders,  but  its  precise  significance  still  requires  determination. 
Urobilinuria  and  bilirubinuria  have  occasionally  been  noted  in  gen- 
eral paresis. 


G  ENEB.  1 L   SYMPTOM  A  TOLOO  Y  OF  L\S.  I XJTY.  6  7  5 

Glycosuria,  with  or  without  polyuria,  lias  often  been  observed  in 
various  organic  psychoses.  Jt  may  be  intermittent,  transitory,  or  per- 
manent. 

Acetonuria  is  encountered  in  general  paresis  and  epilepsy  at  time-,  as 
also  in  psychoses  attended  with  malnutrition,  as,  for  instance,  melancholia. 

Indican  should  be  sought  for,  as  it  is  an  indication  of  albuminous 
putrefaction.     It  is  significant  of  auto-intoxication. 

There  is  a  wide  region  open  to  the  pathological  chemist  for  discov- 
eries in  the  feces,  as  well  as  the  urine,  of  relations  between  metabolism 
and  psycopathic  disorders. 

Menstruation  is  often  disordered  in  insanity.  Amenorrhea  is  the 
rule  in  acute  psychoses  of  any  form,  due  undoubtedly  to  profound 
changes  in  the  general  nervous  system  influencing  the  spinal  centers  for 
ovulation  and  menstruation.  The  cessation  of  menstruation  with  the 
onset  of  an  acute  psychosis  is  often  mistakenly  supposed  by  the  laity  to 
show  some  etiological  relation  between  the  genital  organs  and  the  in- 
sanity. The  return  of  the  menses  is  one  of  the  early  signs  of  con- 
valescence from  acute  mania  and  acute  melancholia.  Naturally,  it 
would  not  be  correct  to  ascribe  amenorrhea  in  all  cases  to  simply  ner- 
vous inhibition,  because  it  may  arise  in  all  kinds  of  psychoses  as  the 
result  of  actual  genital  disease  or  of  marked  anemia. 

Temperature-changes  in  Insanity. — The  physiological  oscillations 
of  temperature  are  greater  and  more  irregular  in  the  insane  than  in 
normal  individuals.  In  general,  however,  insanity  may  be  said  to  run 
a  non-febrile  course. 

Subnormal  temperatures  are  frequently  observed  in  melancholia, 
stuporous  states,  general  paresis,  idiocy,  and  occasionally  in  conditions 
of  great  excitement.  In  these  last  they  are  apt  to  indicate  approaching 
collapse. 

Hypernormal  temperatures  are  found  in  many  psychoses,  sometimes 
from  very  slight  peripheral  irritations,  such  as  retention  of  urine, 
gastric  catarrh,  constipation,  mild  bronchitis,  decubitus,  sometimes  from 
organic  changes  in  thermogenic  centers.  Hysterical  complications  may 
be  associated  with  hysterical  fever.  Motor  agitation  in  mania,  acute 
paranoia,  melancholia,  and  so  on,  may,  if  marked,  give  rise  to  febrile 
symptoms.  The  status  epilepticus  and  convulsive  seizures  of  general 
paresis  increase  the  temperature,  as  a  rule,  to  a  noteworthy  degree. 
Many  writers  have  described  diurnal  oscillations  of  temperature,  varia- 
tions from  day  to  day,  asymmetrical  axillary  temperature,  and  general 
subnormal  and  hypernormal  conditions  of  temperature  in  paralytic 
dementia ;  and  some  years  ago,  in  association  with  Dr.  Langdon,  I 
undertook  a  verification  of  these  statements  at  the  Hudson  River  State 
Hospital  for  the  Insane.1  These  are  the  conclusions  we  drew  from  a 
study  of  the  temperature  in  twenty-five  cases  of  general  paresis  : 

1.  As  regards  the  average  bodily  temperature,  we  find  it  to  corre- 
spond to  physiological  norms.  The  statements  of  our  predecessors  as 
to  hyperpyrexic  or  subnormal  averages  can  not  be  sustained. 

1  "A  Study  of  the  Temperature  in  Twenty-five  Cases  of  General  Paralysis  of  the 
Insane,"  "Journal  of  Nervous  and  Mental  Diseases,"  Nov.,  1893. 


676  MENTAL  DISEASES. 

2.  The  diurnal  oscillations  of  temperature  in  paretics  also  corre- 
spond to  physiological  norms.  The  statements  to  be  found  in  literature 
as  to  extraordinary  daily  variations  being  frequent  in  these  cases  are 
absolutely  erroneous. 

3.  Asymmetrical  axillary  differences  are  so  small  that  they  can  not 
be  considered  as  abnormal,  and  certainly  not  of  any  diagnostic  sig- 
nificance. 

4.  When  unusual  variations  of  temperature  occur  in  general  paretics, 
their  cause  must  be  sought  for  in  conditions  not  related  to  the  patho- 
logical phenomena  of  paralytic  dementia,  but  depending  upon  thermo- 
genic features  unrecognized  by  the  physician,  or  "  masked "  by  the 
mental  state  of  the  patient.  Thus,  in  case  two  of  our  series,  an  in- 
creasing hyperpyrexia  was  noted  during  the  second  week's  observations, 
but  the  pneumonia  causing  it  was  "  masked "  until  the  fifth  or  sixth 
day,  the  patient  dying  on  the  sixth  day.  Again,  in  case  ten,  where  the 
highest  single  daily  oscillation  was  3.4  degrees,  and  the  average  daily 
oscillation  for  the  week  2.2  degrees,  the  patient  suffered  from  bed-sores,, 
which  undoubtedly  produced  some  septicemia.  That  variations  of  tem- 
perature take  place  in  connection  with  the  paralytic  and  convulsive 
seizures  of  these  cases  we  do  not  gainsay. 

Vascular  Disorders. — The  action  of  the  heart  and  vessels  is  often 
influenced  by  insanity.  The  pulse  is  subject  to  acceleration  in  excited 
and  neurasthenic  states,  and  to  retardation  in  stuporous  conditions. 
Variations  in  arterial  tension  are  particularly  noticeable  at  times ;. 
arterial  spasm  in  any  psychosis,  but  especially  in  melancholia,  de- 
pressed types  of  general  paresis,  and  in  paranoia ;  arterial  paralysis  as 
a  sequel  to  this.  No  doubt  strong  mental  shocks  and  depressive  or 
exalting  affects  are  associated  with  anomalies  of  the  vasomotor  innerva- 
tion. Perhaps  many  psychoses  depend  upon  cerebral  angioneuroses. 
The  apoplectiform,  epileptiform,  and  maniacal  seizures  of  general 
paresis  are  believed  to  have  their  origin  in  these.  Precordial  anxiety, 
the  neuropathic  cervical  globus,  and  other  paresthetic  and  paralgesia 
sensations  in  the  domain  of  the  vagus,  are  also,  in  all  likelihood,  due 
to  angioneurotic  conditions. 


CHAPTER  IV. 

EXAMINATION  OF  THE  PATIENT;  DIAGNOSIS;  COURSE 
OF  THE  DISEASE;  PROGNOSIS. 

In  most  cases  of  insanity  the  diagnosis  of  the  presence  of  a  psy- 
chosis and  also  of  the  form  is  by  no  means  difficult ;  but  there  are 
many  in  which  this  is  not  the  case.  Medicolegal  cases  especially  re- 
quire most  careful  and  painstaking  investigation  in  order  to  arrive  at 
exact  knowledge  of    their  mental  state.     It  is  well  to  follow  at  all 


EXAMINATION  OF  THE  PATIENT.  677 

times  sonic  fixed  scheme  of  examination,  and  the  writer  advises  the 

following  : 

1.  Hereditary  factors. 

2.  Pregnancy  and  parturition  of  mother. 

3.  Convulsions  or  other  nervous  disorders  in  infancy. 

4.  At  what  age  did  patient  walk,  speak,  and  complete  dentition  ? 

5.  Degree  and  character  of  education. 

6.  Rachitis  or  febrile  disease  in  childhood. 

7.  Character  and  temperament  in  childhood. 

8.  Period  of  puberty — Was  its  development  normal? 

9.  Strength  of  sexual  instinct  at  this  period  ?     Masturbation? 

10.  Occupation  during  adolescence. 

11.  Character,   temperament,    religion,    physical  condition,  diseases 
during  adolescence. 

12.  Sexual  relations — excessive,  illicit ;  marriage — venereal  disease, 
pucrperium. 

13.  Intemperance  in  the  use  of  alcohol  or  drugs,  overwork,  shock, 
trauma  to  the  head,  infectious  diseases,  genital  disorders. 

14.  Psycopathic  constitution,  previous  attacks. 

15.  History  of  present  attack. 

16.  Probable  etiology. 

Physical    Condition. — 1.  Height,    weight,   nutrition,   circulation, 

pulse,  temperature. 

2.  Cranial  measurements.  1  0        i  t->  •  ! 

o    0, •        ,      £  j  ,.  >  See  chapter  on  Etiology. 

6.  Stigmata  ol  degeneration,     j  l  &* 

4.  Condition  of  heart,  lungs,  alimentary  canal,  genito-urinary 
organs. 

5.  Reflexes,  pupillary  and  tendon. 

6.  Condition  of  cranial  nerves. 

7.  Motor  symptoms — paralysis  or  morbid  movement,  gait. 

8.  Common  sensory  symptoms — paresthesia,  hyperesthesia,  an- 
esthesia. 

9.  Special  sensory  symptoms — sight,  hearing,  smell,  taste,  field  of 
vision. 

10.  Speech    disorders — stammering,    syllabic    articulation,    paretic 
speech,  motor  or  sensory  aphasia,  agraphia,  apraxia,  verbigeration. 

11.  Sleep. 

12.  Expression,  gesticulation,  attitude. 

Psychic  Condition. — 1.  Mode    of  speech — accelerated,  retarded, 
mute,  incoherent. 

2.  Conduct — Does  patient  care  for  his  person  and  dress  ?  Does 
he  attend  to  his  ordinary  duties  ?  Is  he  excited  and  active,  or  depressed 
and  quiet  ? 

3.  Illusions  or  hallucinations  ? 

4.  Mood — Is  the  fundamental  mood  depressed,  exalted,  irritable, 
changeable,  apathetic  ? 

5.  Ethical  feelings — What  is  the  state  of  his  moral  conceptions  and 
judgments  ? 

6.  Attention — Does  the  patient  note  what  goes  on  about  him,  etc.  ? 


678  MENTAL  DISEASES. 

7.  Memory — Weakened  or  increased  as  regards  long  past  and  recent 
events.  Test  mathematical,  geographical,  and  historical  knowledge. 
Test  dates,  ages  and  names  of  members  of  family,  the  events  of  the 
past  few  days,  etc. 

8.  Idea-association — Is  there  apraxia  or  parapraxia?  Does  the 
patient  orient  himself  as  to  place,  time,  and  objects  and  persons  about 
him  ?     Is  the  flow  of  ideas  accelerated,  retarded,  or  incoherent  ? 

9.  Judgment — How  does  he  explain  his  own  morbid  condition  and 
his  relation  to  his  surroundings  ?  What  does  he  busy  himself  with  now, 
and  what  are  his  plans  and  purposes  for  the  future? 

10.  Delusions  and  imperative  ideas. 

From  the  scheme  just  given,  it  will  be  seen  that  the  study  of  a 
case  of  insanity,  and  the  taking  of  the  history  of  the  antecedent  fac- 
tors and  of  the  psychic  disorder  itself,  involve  much  more  elaborate 
attention  than  is  the  case  with  the  ordinary  physical  diseases  which  one 
meets  with  in  practice.  In  medicolegal  cases  we  have  to  guard  against 
several  sources  of  error  in  our  diagnosis,  among  which  are  the  conceal- 
ment of  delusions  by  an  actually  insane  patient  and  the  simulation  of 
insanity  by  a  sane  criminal.  The  forms  of  insanity  usually  simulated, 
because  of  the  facility  of  so  doing,  are  a  maniacal  state,  dementia  or 
stuporous  melancholia,  and  epilepsy  with  insanity.  Only  one  with 
excellent  knowledge  of  the  symptoms  of  insanity  can  simulate  any 
form  of  psychic  disorder  so  well  as  to  defy  the  skill  of  the  physician 
familiar  with  mental  diseases. 

In  general  practice  it  sometimes  occurs  that  peculiar  forms  of  de- 
lirium incident  to  severe  visceral  disease  may  be  at  first  mistaken  for 
insanity.  Thus  I  have,  on  a  number  of  occasions,  been  called  upon  to 
assist  in  the  commitment  of  patients  to  asylums,  where  careful  examina- 
tion showed  the  existence  of  either  a  transitory  delirium  in  association 
with  an  apoplectiform  or  other  organic  lesion  of  the  brain,  or  a  de- 
lirium from  some  such  visceral  condition  as  Bright' s  disease.  Delirium 
of  this  kind  is  distinguished,  first,  by  the  discovery  of  the  associated 
and  causative  organic  disease,  and,  secondly,  by  the  usual  non-conformity 
of  the  delirium  to  any  special  type  of  psychosis. 

Were  I  to  formulate  a  series  of  rules  to  guide  the  examiner  in  his 
investigation  of  the  mental  condition  of  a  patient,  they  would  be  some- 
what as  follows ;  yet  it  is  to  be  remembered  that  these  are  not  fixed 
rules,  but  subject  to  much  modification  by  the  tact,  good  judgment,  and 
common  sense  of  the  examiner  : 

1.  It  is  to  be  presumed  that  previous  to  seeing  the  patient  the 
examiner  has  fully  informed  himself  of  all  of  the  facts  to  be  furnished 
by  relatives  or  friends,  and  has,  when  possible,  inspected  letters  and 
other  writings,  which  so  often  prove  fruitful  sources  of  information. 

2.  Go  to  the  patient  as  a  physician,  and  not  under  the  pretense  of  being 
something  else — a  device  so  often  suggested  by  the  family  and  friends. 

3.  Proceed  to  the  physical  examination  of  the  patient,  during  which 
tactful  questioning  will  determine  the  direction  to  follow  in  further 
inquiries. 

4.  Gain  the  good  will  of  the  patient  by  kindness  and  consideration. 


COURSE  OF  INSANITY.  679 

5.  Even  if  the  patient  is  distrustful  and  uncommunicative,  l><'  politely 
persistent,  and  prolong  the  first  examination,  even  to  the  extent  of  trying 
the  patient,  until  the  object  is  attained  ;  for  many  patients  will,  when 
fatigued,  finally  yield  to  the  friendly  insistence  of  the  examiner. 

G.  If  one  examination  is  insufficient,  however,  have  as  many  inter- 
views as  are  requisite  for  the  purpose  in  view — a  careful  scientific  diag- 
nosis.    In  medicolegal  investigations  this  is  especially  necessary. 

Course  of  Insanity. — In  all  forms  of  insanity  we  should  seek  to 
divide  the  symptoms  presented  into  primary  and  secondary  classes,  nol 
only  because  of  the  interest  of  so  doing,  but  because  of  the  value  of 
the  division  in  the  matter  of  diagnosis.  For  instance,  in  some  cases  we 
discover  hallucinations  and  illusions  to  be  the  primary  symptoms,  and, 
in  addition  to  these,  we  observe,  as  secondary  symptoms,  delusions, 
diminished  attention,  inhibition  of  thought,  motor  inhibition,  and  an 
anxious  state  ;  the  condition  is  that  of  hallucinatory  stupor. 

Furthermore,  we  will  divide  insanities  into  acute  and  chronic  forms, 
referring  usually  rather  to  the  rapid  or  slow  mode  of  onset  than  to  the 
duration  of  the  disease.  But  sometimes  these  qualifications  are  em- 
ployed in  connection  with  the  duration  of  the  insanity.  Thus,  it  is 
customary  in  some  asylums  to  designate  mania  or  melancholia  as  acute 
for  one  year,  at  the  expiration  of  which  the  term  chronic  is  used.  Re- 
missions in  insanity  are  periods  of  improvement  or  apparent  recovery. 
Intermissions,  or  lucid  intervals,  are  periods  of  complete  recovery  be- 
tween attacks. 

Mental  disorders,  owing  to  the  delicate  nature  of  the  physical  struc- 
tures in  which  morbid  changes  take  place,  are  prone  to  run  a  longer 
course  than  diseases  of  other  than  nervous  tissues.  It  is  true  that  tran- 
sitory insanity  and  acute  delirium  may  complete  their  course  in  a  few 
days,  and  that  acute  mania  or  melancholia  may  recover  in  a  month. 
But  three  to  six  months  is  a  better  average  for  acute  mania  and  mel- 
ancholia. Chronic  insanities  may  last  indefinitely,  for,  strangely 
enough,  there  seems  to  be  little  in  these  slow  alterations  of  the  mind  to 
influence  vitality.  The  average  life  of  chronic  lunatics  in  asylums  is 
said  to  be  some  thirteen  years,  to  which,  no  doubt,  the  regularity  of  life 
in  institutions  contributes.  Many  cases  of  marked  chronic  insanity  last 
twenty,  thirty,  even  fifty,  years,  and  over. 

In  any  given  case  of  curable  insanity,  we  usually  discover,  on  ex- 
amination, certain  stages  of  evolution,  prodromata,  complete  develop- 
ment, and  involution  or  convalescence.  Regis  has  devised  charts  which 
show  diagram matically  the  daily  range  of  affects  in  cases  of  acute  mania, 
acute  melancholia,  and  circular  insanity.  In  acute  mania,  for  instance, 
we  note  a  brief  prodromal  stage  of  depression,  followed  by  gradually  in- 
creasing maniacal  excitement,  then  by  gradual  subsidence  of  the  exalted 
stage  to  the  normal  line.  He  should  have  added  before  the  normal  ter- 
mination an  aftermath  of  a  peculiar  tearful  irritability  noticeable  in  these 
cases.  An  analogous  reactive  condition  is  observed  near  the  termina- 
tion of  acute  melancholia  in  recovery — a  certain  morbid  cheerfulness. 

Insanity  terminates  in  recovery,  in  recovery  with  defect,  in  chronic 
persistence  of  the  same  symptoms  as  at  first  manifested,  in  secondary  or 


680  MENTAL  DISEASES. 

terminal  dementia,  or  in  death.  Death  often  arises  from  exhaustion  due 
to  ideomotor  excitement,  and  in  organic  psychoses  from  associated  dis- 
ease of  the  central  nervous  system,  but,  as  a  rule,  death  in  insanity  is 
not  a  consequence  of  the  mental  disorder,  but  of  intercurrent  or  inci- 
dental disease,  such  as  pneumonia,  tuberculosis,  etc.  There  is  great 
variation  as  regards  curability  in  the  different  types  of  psychoses.  For 
instance,  ninety  per  cent,  of  cases  of  simple  melancholia  and  seventy  per 
cent,  of  acute  mania  recover,  while  general  paresis  is  invariably  fatal. 

Prognosis. — The  prognosis  will  depend  upon  several  factors,  among 
which  the  most  important  are  the  type  of  insanity  presented,  the  course, 
the  character  of  certain  symptoms,  and  the  intellectual  development  of 
the  patient. 

As  regards  the  type  of  insanity  presented,  affective  insanities  (mania 
and  melancholia)  are  the  most  curable.  Systematized  chronic  insani- 
ties (paranoia)  and  cyclical  forms  rarely  recover.  Organic  insanities 
are  nearly  always  incurable,  if  not  fatal.  In  mania  and  melancholia, 
the  acuter  the  onset  and  the  more  rapid  and  intense  the  appearance  of 
the  symptoms,  the  better  the  prognosis.  Slow  development  and  prog- 
ress and  partial  remissions  are  unfavorable. 

The  etiology  has  considerable  influence  on  prognosis.  A  transitory 
cause,  like  fright  or  anemia,  is  favorable.  The  older  the  patient,  the 
worse  the  prognosis.  Hereditary  taint  is  not  at  all  unfavorable  as 
regards  recovery  from  an  attack  of  acute  insanity,  but  very  much  so  as 
regards  the  probability  of  relapse.  On  the  other  hand,  a  hereditary 
taint  in  insanity  of  slow  inception  is  of  serious  significance.  Alcohol 
and  morphin,  as  etiological  factors,  influence  prognosis  unfavorably, 
because  of  the  psychic  degeneration  they  superinduce.  Syphilis  is  not 
unfavorable  if  the  insanity  is  due  to  direct  specific  disorders  of  the 
brain,  but  of  bad  import  if  due  to  the  later,  chronic,  diffuse,  specific 
alterations  in  the  central  nervous  system. 

Special  symptoms,  such  as  defect  in  the  intellectual  processes,  sys- 
tematization  of  delusions,  primary  delusions,  paralysis,  and  convulsions, 
are  significant  of  incurability. 

The  lower  the  grade  of  intellectual  development  in  the  patient,  the 
greater  the  danger  of  termination  in  dementia. 


CHAPTER  V. 
GENERAL  TREATMENT  OF  INSANITY. 

It  is  not  so  long  a  time  since  the  insane  in  Christendom  were  be- 
lieved to  be  possessed  of  devils  and  accursed.  On  the  other  hand,  in 
certain  parts  of  heathendom  (among  the  Mohammedans)  it  was  sup- 
posed that  the  souls  of  the  insane  had  been  removed  early  by  God  as  a 


GENERAL    TREATMENT  OF  INSANITY.  Ml 

special  mark  of  favor,  and  that  they  were,  therefore,  blessed.  Medieval 
treatment  was  founded  upon  the  curious  pathology  jusl  described.  One 
portion  of  the  world  ducked,  whipped,  tortured,  chained   in  dungeons, 

and  occasionally  burned,  the  insane.  The  heathen  treated  their  insane 
upon  the  whole,  comparatively  well. 

After  a  time,  many  of  the  therapeutic  measures  employed  by  the 
Europeans  of  the  middle  ages  were  abandoned  as  unsatisfactory.  Bui 
society  still  had  to  be  protected  ;  so  the  insane  were  fettered  in  the  cells 
of  jails  and  fortresses  and  solitary  towers,  until  a  realizing  sense  of  the 
inhumanity  of  such  treatment  struck  a  responsive  chord  somewhere  in 
the  breast  of  a  Tuke,  a  Connolly,  a  Pinel,  a  Rush,  a  Kirkbride,  an 
Earle,  and  doubtless  other,  but  unknown,  immortals  both  before  and 
after  them. 

Insanity  thus  gradually  came  to  be  looked  upon  as  a  disease,  and 
not  a  penal  offense,  and,  instead  of  prisons,  special  buildings  woe  set 
apart  for  the  particular  custody  of  the  insane.  The  great  object  of  the 
asylums  at  first  was  to  afford  protection  to  society  from  lunatics,  to  pro- 
tect them  from  themselves,  and  to  provide  for  their  care  and  support, 
when  at  public  cost,  in  an  economical  manner.  A  hundred  years  ago, 
however,  the  asylum  was  still  a  species  of  jail,  for  its  evolution  had  not 
yet  proceeded  far.  Dungeons  and  iron  chains  and  staples  in  stone 
walls  and  stone  floors  were  still  in  use  in  many  places.  Indeed,  it  is 
scarcely  over  eighty  years  since  Norris,  a  patient  in  Bedlam  (Bethlehem 
Hospital),  in  the  great  Christian  city  of  London,  was  kept  for  twelve 
years  in  a  cell,  with  an  iron  collar  riveted  around  his  neck  and  iron 
bands  and  rings  around  his  wrists,  arms,  and  ankles,  the  neck  being 
fastened  to  the  wall  and  the  leg  to  a  rude  box  of  filthy  straw. 

Asylums  have,  at  the  present  time,  come  to  be  recognized  as  hos- 
pitals, and  they  are  approaching  nearer  to  that  ideal  every  year. 
Occasionally,  one  finds  among  them  some  rudimentary  appendage  which 
is  reminiscent  of  the  embryonal  stage  of  their  evolution  ;  but  this  is, 
fortunately,  rare.  The  well-conducted  hospital  for  the  insane,  to-day, 
is  different  from  the  asylum  of  years  ago ;  the  depressing,  barren  halls 
and  wards  and  naked  floors  have  given  place  to  pleasantly  furnished 
and  carpeted,  cheerful-looking  parlors,  sitting-rooms,  and  bed-rooms  ; 
muffs  and  strait-jackets  have  disappeared  ;  the  unintelligent  attendant 
has,  in  many  instances,  given  place  to  the  trained  nurse  ;  every  new 
means  of  treatment  is  carried  out  to  the  best  of  the  ability  of  the 
asylum  physicians ;  schools,  employment,  theatricals,  music,  and  out- 
of-door  walks  are  provided  in  the  place  of  the  old,  deadly  monotony, 
and,  in  fact,  the  asylum  has  gradually  undergone  a  metamorphosis, 
until  its  character  has  completely  changed.  There  are,  to  be  sure,  not 
many  perfectly  ideal  institutions  as  yet  in  existence,  but  there  are  some 
which  approach  very  nearly  to  it,  as,  for  instance,  that  at  Alt-Scherbitz, 
near  Leipzig,  and  the  new  asylum  at  Rome,  both  of  which  I  visited 
and  described  in  1887. 1  These  are,  of  course,  constructed  on  the  cot- 
tage and  pavilion  plan,  so  arranged  as  to  impress  one  as  small  colonies 

1  "Some  European  Asylums,"  "Amer.  Jour.  Insanity,"  July,  1887. 


682  MENTAL  DISEASES. 

or  villages,  with  separate  buildings  for  those  merely  there  for  custody 
because  of  dangerous  propensities,  those  brought  there  to  be  cared  for 
kindly  during  the  remainder  of  their  useless  lives,  those  who  carry  on 
various  occupations,  and,  finally,  for  such  as  enter  particularly  to  secure 
treatment  for  the  brain-malady  which  has  bereft  them  temporarily  of 
their  reason.  The  colony  system  of  caring  for  the  dependent  classes — 
which  the  writer  thinks  should  ultimately  be  adopted  for  all  kinds  of 
defectives — is  well  exemplified  by  the  Craig  Colony  for  epileptics  in  the 
State  of  New  York. 

I  will  say  that  I  believe  improvement  and  reform  are  constantly 
going  on  in  asylums  throughout  the  world  ;  that  no  one  is  more  anxious 
than  are  their  superintendents  to  make  progress  in  the  care  and  manage- 
ment of  the  insane.  They  are  rapidly  reaching  the  best  methods  of 
dealing  with  the  insane  poor.  If  any  are  tardy  in  this  advance,  it  is 
because  they  are  so  often  hampered  by  the  never-ending  overcrowding 
of  our  public  asylums,  by  the  interference  of  politics,  by  the  lack  of 
money,  by  the  want  of  a  sufficient  number  of  medical  assistants,  and  by 
a  multiplicity  of  official  duties. 

While  these  statements  are  undoubtedly  true, — and  great  credit  is  due 
the  asylum  physicians  of  the  present  day  for  their  strenuous  efforts  in 
behalf  of  their  charges, — I  believe  that  the  ideal  treatment  of  almost  any 
insane  person  is  to  be  sought  outside  of  an  asylum.  After  an  asylum 
experience  of  some  years,  and  an  experience  of  many  years,  too,  in 
private  practice,  I  feel  that  I  am  in  a  position  to  judge  fairly  well  of 
the  relative  merits  of  treatment  in  and  out  of  asylums. 

Theoretically,  it  ought  to  be  the  right  of  every  individual  in  sickness 
to  receive  the  best  treatment  that  medical  science  affords  ;  but  this  right 
can  be  enjoyed  by  very  few.  There  are  too  many  interfering  condi- 
tions. Not  every  injured  man  is  within  reach  of  the  best  surgeon  ;  not 
every  fever-stricken  one  convenient  to  the  best  physician  ;  and  few  are 
the  deaf,  the  blind,  the  lame,  those  with  crippled  bodies  and  those  with 
disordered  minds,  who  ever  really  receive  the  best  treatment  that  the 
world  can  give.  The  intelligent  doctor  and  the  scientific  skill  are  not 
the  only  requisites.  Other  conditions  are  good  nursing,  the  most  suit- 
able climate,  the  best  hygienic  surroundings,  the  best  moral  atmosphere. 
In  dealing  with  affections  of  the  body  solely,  there  is  often  much  to  be 
desired  ;  but  it  is  particularly  in  the  treatment  of  those  who  are  men- 
tally as  well  as  physically  afflicted  that  so  much  which  should  be  done 
is  left  undone.  The  obstacles  in  the  way  of  securing  the  best  treatment 
are  multiplied  in  the  case  of  the  insane  by  the  dethronement  of  the 
supreme  centers  of  psychic  function. 

Just  as  a  hospital  is  a  better  place  than  a  tenement  house  for  a  sur- 
gical patient  or  a  case  of  fever,  so  is  the  asylum  superior  to  the  home 
in  the  caretaking  of  the  pauper  and  indigent  lunatic.  The  acutely 
insane  of  the  poorer  classes  are  best  treated,  at  present,  in  our  large 
public  institutions  ;  and  those  among  the  moderately  well-to-do,  either  at 
home  or  in  the  small  private  asylums.  Only  the  insane  of  the  wealthy 
classes  can,  perhaps,  enjoy  and  carry  out  ideal  methods  of  treatment  in 
their  own  homes,  in  country  houses,  or  in  foreign  travel. 


GENERAL    TREATMENT  OF  INSANITY.  <">*:', 

It  is,  of  course,  needless  to  say  that  there  are  many  degrees  of 
insanity;  that  there  are  hundreds  <>f  cases  thai  are  never  obliged  to  go 
to  an  asylum  at  all ;  that  in  society  are  many  insane  persons  carrying  od 
legitimate  occupations  and  caring  for  themselves  and  families  ;  and  that, 
on  the  other  hand,  there  are  cases  for  which  nothing  but  commitment 
to  an  asylum  would  be  suitable  or  feasible.  But  we  should  not  -end 
any  patient  to  an  asylum  unless  he  needs  restraint  because  of  danger 
to  himself  or  others,  or  because  proper  treatment  and  supervision  are 
difficult  in  his  home,  owing  generally  to  poverty  or  other  insurmountable 
conditions.  The  sooner  a  case  of  acute  insanity  occurring  in  a  pauper 
or  an  indigent  is  removed  to  an  asylum,  the  better  are  his  chances  for 
recovery.  This  merely  signifies  that  the  earlier  treatment  is  undertaken 
by  those  who  are  familiar  with  the  management  and  care  of  the  insane, 
the  better  for  the  patient.  Early  treatment  by  physicians  of  experience 
in  psychiatry  is  demanded.  At  present  this  end  is  best  attained  by 
resort  to  the  asylums  of  the  neighborhood.  But  the  writer  has  often 
called  attention  to  the  need  of  increasing  and  extending  the  facilities 
for  the  early  treatment  of  the  insane — a  matter  which  can  be  accom- 
plished in  several  ways.1      The  lines  of  progress  in  such  direction  are  : 

(1)  The  opening  of  special  reception-wards  or  pavilions  for  the 
insane  in  general  hospitals;  (2)  the  establishment  of  psychopathic  hos- 
pitals in  large  cities ;  (3)  the  creation  of  outdoor  departments  in  con- 
nection with  asylums  situated  in  densely  populous  districts. 

Before  taking  up  the  matter  of  the  treatment  of  insanity,  a  few 
words  should  be  said  as  regards 

Prophylaxis. — Naturally,  the  question  of  the  proper  care  and  edu- 
cation of  children  with  a  tainted  line  or  lines  of  ancestry  often  comes 
before  the  physician.  Much  can  be  done  to  ward  off  impending  future 
evils  by  due  and  early  attention  to  the  mental  and  physical  evolution 
of  such  children.  One  can  not  begin  too  soon  to  regulate  the  life  of 
these  little  ones.  The  very  milk  of  a  weak  and  anemic  mother  may 
diminish  the  feeble  resistance  of  a  degenerate  child.  From  the  day  of 
birth  the  prophylaxis  must  begin.  The  points  to  be  observed  in  the 
effort  to  accomplish  this  are  as  follows  : 

1.  Cultivate  the  body  of  the  growing  child.  Develop  him  physi- 
cally by  careful  and  regular  diet,  regular  hours  of  sleep,  outdoor  life, 
efficient  systems  of  exercise. 

2.  Let  his  training  be  muscular  rather  than  intellectual,  manual 
training  rather  than  lessons,  especially  in  the  early  years  of  childhood. 
No  schools  until  the  age  of  seven  or  eight  years. 

3.  The  child  with  degenerate  tendencies  should  be  forbidden  all 
nervous  stimulants,  such  as  tea,  coffee,  wines,  beer,  tobacco. 

4.  Seek  to  develop  the  resistance  of  the  organism  to  all  external 
stimuli,  hardening  his  body  by  the  daily  morning  cold  bath,  frictions, 
exercise,  a  hard  bed,  a  cold  sleeping-room ;  accustoming  his  mind  to 
the  courageous  endurances  of  pain  and  mental  stresses. 

5.  Guard  well  the  epoch  of  puberty. 

1  "The  Treatment  of  the  Insane  Outside  of  Asylums,"   "Phil.  Med.  News," 
March  11,  1893. 


'684  MENTAL   DISEASES. 

6.  Let  the  occupation  chosen  for  later  years  be  also  one  for  the 
muscles  rather  than  for  the  mind,  an  outdoor  rather  than  an  indoor 
calling,  a  country  rather  than  a  city  life. 

Isolation. — On  being  called  to  see  a  patient  suffering  from  insanity, 
the  first  point  which  arises  is  whether  he  should  be  sent  to  an  asylum 
or  not.  This  is  generally  a  question  of  means.  Isolation  from  the  imme- 
diate friends  is  in  nearly  every  case  a  requisite.  If  the  patient  belongs 
to  the  indigent  or  to  the  middle  classes,  isolation  and  the  best  treat- 
ment for  his  malady  are  only  to  be  satisfactorily  obtained  in  an  asylum 
or  hospital  for  the  insane.  Among  the  well-to-do,  the  needed  isolation 
may  be  successfully  secured  in  his  own  house,  in  an  ordinary  sanatorium, 
or  by  means  of  travel  with  a  suitable  nurse,  companion,  or  physician. 
The  kind  of  treatment  best  adapted  to  the  nature  of  the  case  must  be 
decided  by  the  physician.  The  quiet  of  a  private  house  in  the  city  or 
country  is  best  for  some  cases,  while  the  tonic  and  stimulus  of  foreign 
travel  are  indicated  in  others.  It  may  be  stated  that,  when  travel  seems 
to  be  the  prescription  required,  the  greater  the  change  from  the  envi- 
ronment in  which  the  mental  disorder  developed,  the  better.  The 
cities  of  Great  Britain  and  the  Continent  do  not  differ  essentially  from 
our  own  cities,  and  patients  should  not  be  sent  to  such  places  with  the 
idea  of  securing  a  change  of  environment.  Norway  in  summer,  Egypt 
in  winter,  and  Mexico  in  either  summer  or  winter,  are  regions  which 
offer  the  greatest  inducements  in  the  way  of  tonics  to  the  nervous 
system  and  stimulus  to  the  mind,  and  all  three  are,  at  the  same  time, 
peculiarly  restful  and  calmative. 

If  these  methods  of  home,  country  house,  or  travel  are  for  any 
reason  impracticable,  then  the  smallest  private  asylum  that  can  be  found 
is  to  be  selected,  for  the  fewer  other  insane  persons  and  tl^  greater  num- 
ber of  sane  persons  the  patient  comes  in  contact  with,  the  better  will  be 
his  chances  for  recovery.  There  is  a  need  for  physicians  in  practice  in 
the  country  who  will  be  duly  authorized  and  empowered  by  law  to 
receive  in  their  own  homes  and  care  for  one  such  patient.  The  chief 
drawback  in  home-treatment,  if  long  continued,  is  usually  the  bad  effect 
of  association  with  an  insane  person  upon  other  members  of  his  family, 
particularly  if  they  be  neuropathic.  With  a  sufficiency  of  nurses  and 
room,  there  is  no  contingency  in  the  treatment  of  the  insane  that  can 
not  be  guarded  against.  These  being  provided,  the  worst  features  in  a 
case,  such  as  violence,  homicidal  and  suicidal  tendencies,  attempts  at 
self-mutilation,  etc.,  may  be  as  well  avoided  outside  as  inside  of  an 
asylum.  There  are  cases  in  which — though  I  am  opposed  to  mechanical 
restraint  in  great  measure — I  should  employ  long-sleeved  night-gowns, 
or  even  camisoles,  rather  than  let  them  go  from  home  before  all  means 
of  cure  had  been  tried  at  least  for  a  few  weeks'  time. 

The  conditions  and  propensities  that  we  have  to  combat  are  many. 
The  choice  of  method  must  be  the  result  of  careful  deliberation,  and  after 
judicial  survey  of  all  the  features  presented.  We  usually  need  the 
assistance  of  skilled  and  experienced  nurses.  Thanks  to  the  asylum 
training-schools,  there  are  numbers  of  such  trained  nurses  of  both  sexes 
to  be  had  in  our  large  cities.  , 


GENERAL   TREATMENT  OF  INSANITY. 


TREATMENT  OF  ACUTE  CASES. 

In  acute  cases,  whether  of  mania  or  melancholia,  it  has  been  my 
experience  that  confinement  to  bed  is  a  valuable  factor  in  cure.  Hence. 
on  being  called  to  such  a  ease,  I  have  the  patient  put  to  bed.  Due 
precautions  are  taken  as  to  the  removal  of  all  sharp  instruments, 
weapons,  drugs,  cords,  door-keys,  and  the  like,  and  by  a  simple  device 
the  windows  so  arranged  that  they  may  not  be  opened  beyond  six 
inches;  otherwise  the  furnishings  may  be  left  as  they  are  without 
attention. 

Insomnia  and  mental  and  motor  excitement  most  frequently  demand 
our  best  skill.  In  emergency,  I  am  in  the  habit  of  using  duboisin 
sulphate  hypodermatically  in  the  dose  of  y^¥  of  a  main,  or  sometimes 
hyoscyamin,  or  hyoscin  hydrobromate  in  doses  of  from  yi-^  to  -^  of  a 
grain  hypodermatically,  though  these  latter  are  not  so  satisfactory  as 
duboisin.  But  for  routine  treatment  of  insomnia  and  maniacal  excite- 
ment I  much  prefer  hydrotherapy  to  drugs.  In  some  cases  the  pro- 
longed warm  bath  (70°-90°  F.)  for  from  one-half  to  two  hours  may  be 
used,  but  in  all  cases  the  hot  wet-pack  is  applicable.  Sometimes  when 
the  wet-pack  does  not  suffice  to  quiet  fierce  maniacal  excitement,  I  use 
duboisin  in  addition,  or  give  doses  by  the  mouth  of  paraldehyd,  trionalr 
and  sulphonal,  all  of  which  are  valuable  hypnotics. 

In  acute  depressed  conditions,  on  the  other  hand,  opiates  usually  act 
best  in  cases  in  which  hydrotherapy  does  not  subdue  the  insomnia,  dis- 
tress of  mind,  and  disordered  nervous  system.  Among  opiates,  codein 
seems  to  offer  advantages  over  others,  and  the  contraction  of  a  habit 
need  not  be  feared.  The  aqueous  extract  of  opium  or  morphin  may 
be  given  hypodermatically. 

The  refusal  of  food  is  another  element  of  danger.  Acute  insanity,, 
besides  rest  in  bed,  quiet,  and  repose,  needs  overfeeding  to  balance  the 
great  waste  of  tissue  going  on  in  the  system.  While  many  cases  of 
acute  mania  will  eat  and  drink  ravenously  at  times,  from  the  nature  of 
things  their  actions  are  uncertain,  and  the  nurse  should  be  instructed 
to  feed  the  patient  almost  hourly  and  keep  account  of  what  is  given. 
Milk,  raw  eggs,  meat-juice,  and  occasional  stimulants  must,  in  extreme 
cases,  be  our  chief  reliance.  Having  an  intelligent  and  assiduous  nurse 
at  hand,  the  necessity  of  feeding  with  a  tube  will  only  rarely  occur. 
When  required,  the  soft  rubber  stomach-tube  may  be  introduced  by  the 
physician  through  the  mouth  or  nose,  a  funnel  attached,  and  the  liquid 
mixture  of  the  substances  named  allowed  to  flow  in. 

There  are  cases  (some  of  the  insanities  of  puberty  and  adolescence, 
and  other  forms)  in  which  anaphroclisiacs  modify  distinctly  the  trend  of 
delusions.  There  are  cases  in  which  intestinal  antiseptics  achieve  note- 
worthy results ;  indeed,  the  instances  are  few  in  which  attention  to 
morbid  states  of  the  alimentary  canal  is  not  rewarded  by  considerable 
benefit  to  the  mental  condition  of  the  patient.  Arguments  with  patients 
upon  delusions,  more  or  less  fixed  in  character,  often  has,  despite  the 
opinions  of  numerous  alienists  to  the  contrary,  decided  value  in  altering 


686  MENTAL  DISEASES. 

their  beliefs,  and  at  times  even  eradicating  their  insane  ideas  altogether. 
It  is  true  that  occasional  argument  is  generally  of  no  avail.  Such  moral 
treatment  must  be  sedulously  and  perse veringly  employed,  daily  and  for 
weeks  or  months,  to  insure  success.  Argument  is  a  species  of  sugges- 
tion. The  tactful  and  judicious  physician  will  not  make  use  of  it  in 
cases  where  it  leads  to  irritation  and  would  seem  to  be  injurious. 

The  most  important  remedial  agents  employed  in  insanity  are  as 
follows  : 

The  Rest-cure. — This  has  already  been  briefly  referred  to.  It  was 
in  1860  that  Hilton  began  his  series  of  lectures  on  rest  and  pain,  in 
which  he  pointed  out  how  much  rest  had  to  do  with  growth  and  repair 
of  the  bodily  tissues,  and  fifteen  years  later  Mitchell  wrote  of  the  value 
of  rest  in  the  treatment  of  hysteria  and  neurasthenia.  Nowadays, 
however,  we  apply  the  principle  of  rest  to  a  great  variety  of  nervous 
disorders.  Besides  its  indication  in  many  cases  of  hysteria  and  neuras- 
thenia, we  find  it  of  the  greatest  benefit  in  all  sorts  of  nervous  and 
mental  troubles,  and  especially  in  such  as  evince  a  tendency  to  waste  of 
tissue  and  to  exhaustion. 

Most  cases  of  acute  mania  need  to  be  treated  by  rest,  which  should 
be  made  as  absolute  as  possible.  Many  cases  of  acute  melancholia 
recover  more  quickly  when  confined  to  bed.  While  in  many  mental 
cases  the  rest  should  be  absolute  for  a  period  of  several  weeks  in  order 
to  insure  a  successful  termination,  it  is  astonishing  how  much  benefit 
can  be  obtained  by  a  modified  rest  treatment — that  is,  by  merely  pro- 
longing the  daily  amount  of  repose  in  bed.  The  principle  is  to  apply 
rest  methodically,  and  in  proportion  to  the  degree  of  nervous  exhaus- 
tion, strain,  or  irritation. 

When  rest  is  made  nearly  absolute,  it  is  necessary  that  tissue  meta- 
bolism should  be  encouraged  by  attention  to  the  amount  and  quality 
of  food,  and  especially  by  substitution  of  some  passive  artificial  exer- 
cise for  the  active  movements  upon  which  the  organism  has  hitherto 
depended.     This  is  accomplished  chiefly  by  massage. 

Massage. — Massage  was  a  favorite  remedy  and  luxury  in  ancient 
Roman  times,  when  it  figured  as  the  Aliptic  Art  ;x  so  that  it  is  not  at  all 
a  new  remedy,  but  its  vogue  in  recent  years  has  assumed  enormous  pro- 
portions, and  it  has  received  a  scientific  study  and  systematization  to 
which  the  ancients  were  strangers.  This  rubbing,  beating,  and  knead- 
ing of  the  trunk  and  limbs,  when  skilfully  done,  is  an  essential  adjunct 
to  the  absolute  rest  treatment.  It  is  invaluable  in  many  kinds  of  pain, 
and  it  often  surpasses  drugs  as  a  soother  of  irritation  and  an  inducer  of 
sleep. 

Diet. — It  is  needless  to  say  that  in  connection  with  a  form  of  rest 
treatment  simplicity  should  be  the  rule  as  regards  food.  The  selection 
should  be  made  from  the  point  of  view  of  easy  digestibility,  and  fore- 
most in  this  regard  stand  milk  and  its  various  preparations.  Where 
milk  can  not  be  taken  in  its  ordinary  form,  some  more  digestible  prepa- 
ration may  be  employed,  such  as  peptonized   milk,  koumiss,  matzoon, 

1  "The  Aliptic  Art:  a  Historical  Study,"  by  the  author,  "Phil.  Med.  News," 
Aug.  11,  1883. 


GENERAL   TREATMENT  OF  TNBANITY.  687 

or  soraal.  In  cases  undergoing  a  rest  treatment  this  is  the  main  staple 
of  food,  and  it  should  be  given  frequently  and  in  considerable  quantity. 
Overfeeding  is  indeed  another  principle  in  the  treatment  of  any  of  the 
nervous  and  mental  diseases  in  which  exhaustion  is  a  feature.  Thus, 
absolute  rest  and  overfeeding  must  be  our  chief  reliance  in  acute  mania, 
and  in  severe  types  of  melancholia.  Many  cases  require  feeding  every 
hour  or  two  hours.  Raw  or  soft-boiled  eggs,  rare  or  raw  beef,  specially 
prepared  cereals,  and  sometimes  green  vegetables  and  fruits  may  be 
added  to  the  diet.  (By  specially  prepared  cereals  I  mean  simple  boiled 
rice,  stale  bread  in  the  form  of  toast,  or,  better,  bread  which  has  been 
twice  baked — Zwieback).  Stimulants  are  only  occasionally  indicated, 
and  then  especially  in  acute  maniacal  or  other  dangerously  exhausting 
conditions. 

A  somewhat  similar  form  of  diet  is  appropriate  for  mental  disturb- 
ances having  a  rheumatic  or  gouty  diathesis  as  a  basis.  The  same  diet 
is  essential  in  all  cases  of  insanity,  neurasthenia,  epilepsy,  and  so  on, 
which  seem  to  depend  upon  auto-intoxication  from  fermentative  or 
putrefactive  changes  in  the  intestinal  contents,  and  such  cases  we  find 
nowadays  to  be  not  at  all  infrequent. 

Hydrotherapy. — When  in  1893  I  wrote  a  paper  on  "  Hydrotherapy 
in  the  Treatment  of  Nervous  and  Mental  Diseases  "  ("  Amer.  Jour,  of 
the  Med.  Sciences,"  February,  1893),  there  was  really  no  place  in  the 
city  of  New  York  to  which  one  could  send  patients  and  have  his  own 
ideas  as  to  treatment  faithfully  carried  out ;  nor  did  I  know  of  a  single 
asylum  for  the  insane  in  this  country  installed  with  hydrotherapeutic 
apparatus,  such  as  I  had  seen  in  a  number  of  asylums  abroad,  even 
in  so  remote  a  country  as  Greece.  Now  I  could  name  many  public 
and  private  asylums  which  are  equipped  with  arrangements  for  this 
purpose. 

Water  affects  the  nervous  in  a  variety  of  ways. 

Cold  baths  increase  and  warm  baths  diminish  the  irritability  of  the 
brain  and  spinal  cord  in  a  reflex  manner  by  stimulating  the  sensory 
and  vasomotor  nerves  of  the  skin,  thus  influencing  the  cerebrospinal 
circulation. 

Short  cold  baths,  especially  when  combined  with  sprinkling,  shower- 
ing, or  rubbing,  are  powerfully  stimulating,  exhilarating,  and  tonic. 
Cold  baths  stimulate  peristalsis  and  the  visceral  reflexes  in  the  cord, 
and  increase  blood-pressure.  Prolonged  warm  baths,  steam  and  hot- 
air  baths,  and  the  hot  pack  are  relaxing,  fatiguing,  and  tend  to  induce 
sleep.  Warm  baths  diminish  arterial  tension  and  reduce  the  irritability 
of  individual  nerves  and  the  whole  nervous  system.  The  spinal  douche 
is  of  the  greatest  service  in  many  nervous  disorders,  because  of  its  re- 
markable tonic,  revulsive,  and  derivative  effects.  It  is  a  powerful 
mental  as  well  as  physical  stimulus.  By  means  of  various  nozles  it  is 
ejected  in  the  form  of  a  strong  stream  up  and  down  the  back  of  the 
patient  for  a  few  seconds  only,  at  a  distance  of  some  ten  feet.  Patients 
with  good  reaction  do  not  need  any  special  preparation,  but  at  the 
beginning  it  is  well  to  have  the  patient  take  a  warm  bath  or  stay  a  few 
minutes   in   a  hot-air  box    previous  to  its   application.     At  the  first 


688  MENTAL  DISEASES. 

seances  the  water  should  not  be  too  cold.  Later,  it  may  be  gradually- 
lowered  to  50°  F.  It  should  be  taken  every  day,  when  possible.  Oc- 
casionally this  cold  spinal  douche  is  alternated  with  a  hot  douche  (the 
so-called  Scotch  douche).  This  is  an  exceedingly  successful  procedure 
in  many  cases  of  hysteria,  neurasthenia,  and  in  lethargic  and  hysterical 
forms  of  insanity,  where  there  are  sluggish  intellect,  great  depression, 
apathy,  stupor,  catalepsy,  etc.,  and  in  any  case  of  nervous  and  mental 
disease  where  anemia,  chlorosis,  or  gastric  trouble  exists. 

In  insomnia  there  is  no  other  remedy  so  generally  efficient  and  at 
the  same  time  so  innocuous.  I  have  seen  it  successful  in  wake- 
fulness from  every  kind  of  cause,  and  in  cases  seemingly  intractable 
to  other  remedies.  There  are  two  hydriatic  procedures  for  the 
production  of  sleep.  One  is  the  prolonged  warm  whole  bath,  at  a 
temperature  of  70°  to  90°  F.,  for  from  one-half  to  two  hours  just  before 
retiring.  This  is  indicated  in  mild  cases  of  insomnia.  But  the  hot 
wet-pack  is  more  effectual  and  more  widely  applicable  in  all  forms  of 
sleeplessness,  whether  in  nervous  or  insane  individuals.  It  is  applied 
in  this  way  :  A  blanket,  nine  by  nine  feet,  is  spread  upon  the  patient's 
bed,  and  upon  this  a  sheet,  wrung  out  dry  after  dipping  in  hot  water,  is 
laid.  The  patient  lies  down  upon  this,  and  the  sheet  is  at  once  evenly 
arranged  about  and  pressed  around  the  whole  body,  with  the  exception 
of  the  head,  after  which  the  blanket  is  also  immediately  likewise  closely 
adjusted  to  every  part  of  the  patient's  body.  Other  dry  blankets  may 
now  be  added  as  seems  necessary.  The  patient  remains  in  this  an  hour 
or  longer ;  all  night,  if  asleep. 

I  know  of  no  better  treatment  of  acute  maniacal  conditions,  for 
instance,  than  rest  in  bed,  overfeeding,  the  hot  wet-pack,  and  the  occa- 
sional employment  of  some  sleep-producing  agent. 

Treatment  of  Auto-intoxication. — Researches  in  the  physiologi- 
cal chemistry  of  digestion,  as  well  as  observations  in  many  pathological 
conditions,  have  established  that  auto-intoxication  from  the  absorption 
of  poisonous  substances  generated  in  the  alimentary  canal  by  putre- 
factive and  fermentative  processes  is  not  only  a  real  thing,  but  a  fre- 
quent factor  in  the  etiology  of  a  number  of  nervous  disorders,  such  as 
headache,  neurasthenia,  hysteria,  neuralgia,  and  even  graver  maladies, 
like  epilepsy,  melancholia,  mania.  It  behooves  us,  therefore,  in  these 
diseases,  to  investigate  carefully  for  evidence  of  any  such  cause.  Peri- 
odical or  constant  attacks  of  gaseous  diarrhea  are  somewhat  indicative 
of  this  condition.  Frequently  the  condition  of  the  bowels  furnishes  no 
information  of  the  actual  state  of  aifairs.  Recent  researches  tend  to 
show  that  an  excess  of  ethereal  sulphates  in  the  urine  (indican)  in 
connection  with  other  symptoms  is  a  good  index  of  auto-intoxication. 

When  auto-intoxication  is  suspected  as  the  causative  factor  in  any 
nervous  disorder,  it  is  essential  to  regulate  the  diet  in  the  manner 
already  mentioned,  and  there  are  at  our  disposition  a  number  of  intes- 
tinal antiseptics  which,  though  not  always  efficient,  are  yet  often  of 
very  great  benefit.  I  have  found,  in  my  own  practice,  that  beta- 
naphtol  is  one  of  the  best  intestinal  antiseptics.  I  give  it  in  capsules 
of  five  grains  each,  two  hours  after  eating,  with  water.    In  several  cases 


GENERAL    TREATMENT  OF  INSANITY. 

of  epilepsy  and  of  melancholia  it  lias  acted  exceedingly  well.  In  many 
cases  of  epilepsy  salicylate  of  soda  has  also  proved  itself  of  great  value. 
Salol,  too,  is  a  good  intestinal  antiseptic.  Sometimes  J  have  made 
excellent  use  of  peppermint  for  the  same  purpose.  I  think  the  abun- 
dant use  of  water  a  necessary  adjunct  in  the  treatment,  usually  advising 
the  drinking  of  hot  water  several  times  daily  on  an  empty  stomach,  and 
sometimes  adding  thereto  frequent  flushing  of  the  large  intestine  with 
warm  water. 

Electrotherapy. — General  faradization  with  a  current  sufficiently 
strong  to  contract  the  muscles  lias  much  the  same  value  as  massage 
where  the  rest-cure  is  employed;  it  exercises  the  muscles  and  stimulates 
metabolism.  Over  and  above  this  it  has  a  tonic  effect.  Galvanism  is 
only  of  use  in  complicating  conditions,  such  as  neuralgias,  sciatica,  and 
the  like.  The  same  is  true  of  the  static  and  sinusoidal  currents. 
Electrization  of  the  head  for  the  purpose  of  influencing  illusions,  hal- 
lucinations, and  delusions  is  occasionally  of  service,  but  doubtless  its 
influence  is  almost  wholly  of  a  suggestive  nature.  However,  it  is  not 
to  be  interdicted  on  that  account,  for  suggestion  is  in  itself  a  valuable 
therapeutical  adjunct,  and  so  good  a  method  of  increasing  its  usefulness 
as  is  afforded  by  electricity  is  not  to  be  slighted.  Suggestion  is  a  species 
of  psychic  therapy. 

Drugs. — The  narcotics  are  of  great  importance  in  the  treatment  of 
insanity.     Among  these,  opium  and  its  alkaloids  easily  stand  first. 

Opium,  morphin,  codein,  all  have  a  hypnotic  effect,  but  their 
especial  value  lies  in  their  sedative  influence  upon  mental  hyperesthesia, 
anxious  states,  etc.;  in  their  contraction  of  the  blood-vessels,  and  in 
their  stimulation  of  the  nutrition  of  the  central  nervous  system.  The 
hypodermatic  use  is  best.  They  are  particularly  indicated  in  melan- 
cholia, acute  alcoholic  psychoses,  and  hallucinatory  paranoia,  very 
seldom  in  maniacal  states.  They  are  contraindicated  in  most  maniacal 
conditions,  collapse,  fatty  heart,  uncompensated  valvular  disease,  and 
marasmus.  The  patient  should  not  know  the  name  of  the  drug  used. 
Opium  and  codein  are  preferable  always  to  morphin,  because  of  less 
danger  of  forming  a  habit.  The  doses  must  be  gradually  increased. 
The  constipation  at  first  present  during  the  administration  of  opiates 
disappears  later. 

Hyoscin,  hyoscyamin,  and  duboisin  are  isomeric  alkaloids,  and 
have  much  the  same  qualities  and  are  alike  in  their  effects  upon  the 
organism.  Next  to  the  opiates  they  form  the  chief  drugs  of  the 
alienist's  armamentarium.  Their  great  value  lies  in  their  sedative 
influence  upon  motor  centers.  They  are  used  hypodermatically  in  doses 
of  from  yi^  to  jL  of  a  grain.  Almost  immediately  after  injection  the 
muscles  become  incodrdinated  and  weak,  and  in  ten  or  fifteen  minutes 
the  patient  sinks  into  a  light  slumber  which  lasts  from  six  to  eight 
hours.  The  peripheral  arteries  are  contracted,  giving  the  patient  a 
striking  pallor;  the  breathing  is  slowed,  the  pulse  retarded  or  made  in- 
termittent, the  throat  rendered  very  dry,  and  the  pupils  enlarged  and 
accommodation  paralyzed.  These  drugs  are  contraindicated  in  heart 
disease,  and  in  no  case  should  they  be  continued  any  length  of  time. 
44 


690  MENTAL  DISEASES. 

Precious  as  they  are  on  the  right  occasion,  their  employment  should  be 
subject  always  to  the  careful  and  judicious  supervision  of  the  physician. 
Another  feature  of  their  physiological  action  to  be  borne  in  mind  is 
their  power  to  induce  dreadful  hallucinations  in  a  well  person — a  fact 
which  emphasizes  the  need  of  care  in  administering  them  to  an  indi- 
vidual whose  mind  is  trembling  in  the  balance.  Long-continued  use 
of  these  alkaloids  interferes  with  nutrition. 

From  what  has  been  said  of  the  action  of  these  drugs,  it  will  be  seen 
that  their  effectiveness  is  most  manifest  in  conditions  of  motor  excite- 
ment, in  mania,  agitated  melancholia  (combined  with  morphia),  in 
agitated  dementia,  and  in  the  motor  excitement  of  epilepsy  or  paresis. 
I  have  often  been  able  to  feed  excited  patients  who  refused  food,  imme- 
diately after  the  injection  of  the  alkaloid,  during  the  few  minutes  that 
elapse  before  the  advent  of  sleep. 

The  bromids,  aside  from  their  particular  value  in  epileptic  psy- 
choses, are  often  useful  in  other  forms  of  mental  disease,  owing  to  their 
effect  in  diminishing  cerebral  activity  and  reflex  irritability.  In  epilep- 
tic insanities  the  combination  of  the  bromids  and  opium  is  especially 
effective.  They  are  of  use  in  any  mental  excitement  which  is  con- 
joined with  some  reflex  irritability  (illusions  and  organic  sensations, 
uterine  and  genital  disorders).  As  an  anti-aphrodisiac  they  are  employed 
in  insanity  with  erotic  manifestations.  In  large  doses,  sixty  to  ninety 
grains  and  over,  they  act  well  as  a  safe  and  innocuous  hypnotic. 

Chloral  hydrate  is  not  so  much  used  as  formerly,  though  its  hyp- 
notic effect  resembles  very  closely  natural  sleep.  It  is  applicable  to 
acute  hallucinatory  conditions,  insanities  associated  with  chorea,  and  in 
the  epileptic  psychoses.  In  status  epilepticus,  per  rectum  it  is  one  of 
the  most  valuable  remedial  agents.  In  some  conditions,  combinations 
of  chloral  with  morphin  are  of  much  utility.  Chloral  is  a  heart  poison, 
and  its  use  is  contraindicated  in  cardiac  and  vascular  disease.  Chloral- 
amid  is  of  little  value. 

Paraldehyd  is  a  simple  hypnotic  whose  utility  is  not  sufficiently 
appreciated.  Naturally,  its  bad  taste  and  the  rather  disagreeable  odor 
left  upon  the  breath  have  limited  its  sphere  of  usefulness ;  but  it  has 
no  bad  influence  upon  the  heart  or  nutrition.  It  can  be  given  in  heart 
disease,  and  patients  seem  to  thrive  and  grow  fat  upon  it.  The  dose  is 
from  one-half  to  two  drams,  but  increasing  doses  are  necessary,  and  I 
have  had  patients  who  have  taken  four  or  more  drams  at  a  dose.  It  is 
especially  useful  in  conditions  of  inanition  and  in  insanities  founded 
upon  hysteria  or  neurasthenia.  The  taste  and  odor  of  the  drug  can  be 
concealed  in  orange-water  or  weak  brandy.  Amylene  hydrate  is  of  less 
value  ;  it  stands  between  chloral  and  paraldehyd. 

Trional  and  sulphonal,  as  simple  sleep-producing  agents,  are  preemi- 
nent where  nothing  but  sleep  is  the  object  to  be  attained.  Trional  acts 
quickly,  sulphonal  slowly  ;  hence  a  combination  of  the  two  in  equal  doses 
is  particularly  fortunate  in  its  results,  inducing,  as  it  does,  rapid  and 
prolonged  slumber.  Five  to  ten  grains  each,  or  more  if  indicated,  may 
be  given  at  bedtime  with  a  glass  of  hot  milk.  The  tastelessness  of  these 
drugs  affords  the  possibility  of  administering  them  without  the  knowledge 


GENERAL    TREATMENT   OF   INSANITY.  691 

of  the  patient,  mixed  with  salt  or  sugar,  or  spread  with  butterupon  bread. 
Sulphonal  used  for  a  long  period  produces  muscular  weakness  and  in- 
coordination. Botli  of  these  agents  may,  after  a  time,  give  rise  to  some 
disorder  of  the  alimentary  canal.  They  are  said  to  occasionally  increase 
the  intensity  of  auditory  hallucination-. 

Moral  Treatment. — Psychotherapy  is  among  the  most  important 
means  of  treatment  of  insanity.  The  general  practitioner  is  especially 
concerned  with  it  in  the  early  stages  of  mental  disorder;  later,  if  the 
patient  is  turned  over  to  the  care  of  the  asylum,  it  is  still  of  the  utmost 
importance,  and  the  physicians  in  institutions  know  well  the  necessity 
and  utility  of  moral  agencies  in  effecting  a  cure  or  in  :it  least  amelio- 
rating the  condition  of  their  charges.  Physicians  who  have  much  to  do 
with  ordinary  functional  nervous  disorders — hysteria,  neurasthenia,  mild 
depression,  and  hypochondriasis — are  familiar  with  the  wonderful  influ- 
ence they  are  able  to  exert  over  the  mental  attitude  of  patients  thus 
afflicted,  by  kindness,  patience,  firmness,  interest,  and  sympathy.  Every- 
thing they  say  or  do,  if  rightly  said  or  done,  conveys  a  suggestion, 
inspires  hopefulness,  increases  the  efficacy  of  their  prescriptions,  points 
out  the  way  to  health  and  a  new  lease  of  life.  The  insane  also  are  in 
the  same  way  dominated  by  the  personality  of  the  physician  and  of 
those  chosen  to  carry  out  his  instructions.  Some  physicians  are  fortu- 
nate enough  to  possess  peculiar  gifts  in  this  way,  and  their  influence  is 
potent  for  incalculable  good.  Aside  from  this  personal  influence,  the 
physician  is  called  upon  to  direct  and  regulate  the  entire  disposition  of 
the  time  of  the  patient  and  to  make  for  him  the  environment  suitable  to 
his  malady.  He  prescribes  isolation  from  friends,  the  care  of  strangers, 
the  rest-cure,  the  periods  and  kinds  of  exercise,  the  mental  and  manual 
occupations,  the  amusements,  all  of  which  go  to  make  up  psychotherapy. 
Some  of  the  principles  of  this  moral  treatment  we  will  now  briefly  touch 
upon. 

The  value  of  isolation  in  melancholia  and  of  the  rest-cure  for  both 
acute  mania  and  melancholia  has  already  been  mentioned.  There  are 
cases  of  melancholia,  however,  in  which  a  modified  rest-cure  is  better 
than  the  complete  rest-cure.  In  such  cases,  after  recumbence  in  bed 
from  six  in  the  evening  until  noon  the  next  day,  much  of  the  afternoon 
may  be  spent  in  simple  exercise,  such  as  walking  slowly  about  out-of- 
doors.  It  is  best  not  to  seek,  by  amusements,  visits  of  friends,  and  other 
cheerful  devices,  to  raise  the  melancholiac  from  his  depression,  for  usually 
these  attempts  rather  add  to  his  misery  by  force  of  contrast.  A  neutral 
atmosphere,  so  far  as  the  emotions  are  concerned,  is  best,  though  an 
occasional  word  of  confident  reassurance  is  useful. 

In  acute  stages  of  insanity  it  is  best  not  to  discuss  the  hallucinations 
and  delusions  of  the  patient,  although  neither  physician  nor  nurse 
should  ever  fall  in  with  or  act  upon  his  erroneous  ideas.  Whenever 
good  judgment  suggests,  a  brief  but  positive  denial  of  the  truth  of  the 
imaginings  of  the  patient  should  be  made.  Later  on  such  correction 
may  with  advantage  be  made  more  frequently  and  constantly. 

When  the  patient  is  not  taking  a  rest-cure,  occupation  of  some  kind 
is  essential  to  his  progress  toward  recovery.     Most  useful  are  all  forms 


692  MENTAL  DISEASES. 

of  muscular  or  manual  employment,  for  labor  of  this  kind  keeps  the 
attention  more  or  less  fixed  upon  what  is  being  done,  the  flow  of  ideas 
is  checked  and  limited  to  a  considerable  degree,  and  the  mind  is  pre- 
vented from  concentrating  itself  upon  illusions,  hallucinations,  and 
delusions.  Moreover,  muscular  exercise  is  an  outlet  for  superfluous 
energy  ;  motor  excitement  is  reduced  by  it ;  tissue  metabolism  is  accel- 
erated ;  and  when  the  work  is  over,  the  organism  gains  all  the  more 
readily  a  certain  composure  of  mind  and  repose  of  body.  Out-of-door 
occupation  is  best — garden  and  field  work  for  men,  garden  work  for 
women  ;  walking,  bicycling,  etc.,  for  either  sex.  Among  indoor  em- 
ployments we  have  ordinary  housework,  drawing,  knitting,  sewing, 
embroidery,  carpentry,  wood-carving,  etc.,  all  of  which  employ  the 
muscles  methodically.  In  certain  cases  mental  occupation  is  useful, 
though  it  should  be  of  the  simplest  kind.  For  instance,  during  my 
practice  at  the  Hudson  River  State  Hospital  for  the  Insane,  we  found 
much  value  in  the  establishment  of  a  regular  country  school,  attended 
by  patients  of  all  ages.  We  had  "  spelling  bees,"  copying  lessons, 
reading  aloud,  blackboard  exercises,  geography,  simple  arithmetic,  sing- 
ing, and  so  on. 

A  very  important  point  in  the  management  of  the  insane  is  never  to 
practise  deception  upon  them  in  any  way.  Be  absolutely  truthful  in 
every  statement  to  them.  Never  remove  a  patient  to  an  asylum  under 
the  impression  that  it  is  a  hotel  or  sanatorium.  It  is  better  to  state 
exactly  what  is  going  to  be  done,  and  then  use  force  in  the  removal,  if 
necessary. 

Hypnotism  has  been  frequently  practised  upon  the  insane,  in  the 
eifort  to  modify  hallucinations  or  delusions,  rarely  with  any  definite 
success,  occasionally  with  ill  results,  and  generally  with  no  effect  what- 
ever. 

There  are  a  few  conditions  among  the  insane  which  require  particular 
treatment  or  management.     Among  them  are  : 

Suicidal  Tendencies. — Suicidal  patients  are  among  those  who 
require  constant  watching  and  the  removal  of  every  means  of  self- 
injury.  This  is  often  difficult  in  treating  such  patients  in  their  own 
homes.  How  difficult,  it  may  be  conjectured  from  the  fact  that,  even  in 
asylums,  with  all  their  safeguards,  suicide  is  by  no  means  infrequent. 
Thus,  forty-eight  patients  in  the  asylums  of  the  State  of  New  York 
committed  suicide  between  October  1,  1888,  and  September  30,  1896. 

Suicidal  patients  are  to  be  watched  night  and  day,  and  kept  in  bed, 
and  even  put  in  restraint,  if  desperate.  I  have  known  a  patient  to 
strangle  herself  with  a  cord  while  lying  in  bed  under  the  eye  of  a 
nurse.  Another,  broke  a  small  piece  from  a  china  plate  and  tried  to  cut 
her  wrists  under  the  bedclothes.  While  suicide  is  most  common 
among  melancholiacs,  patients  with  general  paresis,  paranoia,  epileptic 
psychoses,  and  toxic  delirium  sometimes  attempt  it.  The  physician 
attending  such  patients  should  see  to  the  guarding  of  windows  and  the 
removal  of  keys,  hooks,  scissors,  weapons,  drugs,  strings,  long  pins, 
matches — in  fact,  of  all  instruments  and  means  which  he  may  suspect 
to  be  utilizable  for  a  suicidal  purpose. 


GENERAL    TREATMENT  OF  INSANITY.  693 

Refusal  of  Food. — The  acutely  maniacal  often  can  not  be  made  to 
take  sufficient  nourishment,  because  they  do  not  .stop  long  enough  in 
their  ideomotor  excitement  to  permit  of  eating.  The  watchful  and  per- 
severing nurse  can  generally,  by  persistent  effort,  induce  the  patient  to 
swallow  a  considerable  quantity  of  liquid  food  (preferably  in  a  metal  or 
heavy  china  cup,  because  the  patient  frequently  knocks  the  vessel  from 
the  hand  of  the  nurse).  Such  patients  can  often  be  fed,  as  already 
stated,  immediately  after  a  hypodermatic  injection  of  hyoscin  or  duboi- 
sin  before  the  supervention  of  sleep. 

Other  patients  refuse  to  eat  because  of  delusions  of  poverty  or 
poisoning,  suicidal  proclivity,  or  simply  from  absolute  distaste. 

Where  ordinary  means  fail,  the  nasal  tube  should  be  resorted  to, — 
one  of  large  caliber  with  rubber  funnel  attached, — and  through  this, 
once  or  twice  daily,  a  mixture  of  a  pint  of  milk,  two  or  three  raw  eggs, 
a  little  meat-juice,  and,  if  needed,  brandy,  may  be  introduced. 

Before  resort  to  this  means  nutritive  enemata  may  be  employed 
(three  raw  eggs,  a  half-pint  of  milk,  a  half-pint  of  water,  and  a  little 
meat-juice). 

I  have  been  in  the  habit  of  delaying  the  use  of  the  nasal  or  stomach- 
tube  to  the  last  moment  of  safety,  even  for  several  days,  rather  than 
subject  the  patient  to  the  excitement  of  its  employment.  It  is  only  in 
rare  instances  that  feeding  is  not  effected  in  some  other  way  before  the 
use  of  the  tube  becomes  imperative. 

Violence  and  Destructiveness. — Hypodermatic  medication  and  hot 
wet-packs  are  indicated  in  periods  of  excitement  with  tendency  to  vio- 
lence and  destructiveness.  It  has  already  been  intimated  that  active 
physical  labor  or  exercise  is  a  safety-valve  for  patients  with  proclivities 
of  this  kind.  Isolation  in  an  empty  room  with  protected  windows  is 
sometimes  resorted  to  in  institutions,  and  abroad  the  padded  room  is  a 
favorite  place  for  patients  whose  violent  jactitations  may  lead  to  serious 
injuries  to  himself.  The  padded  room  consists  simply  of  a  room  lined 
as  to  walls  and  floor  with  cushions.  Mechanical  restraint  is  used  in  the 
last  extremity,  when  chemical  restraint  and  other  means  have  failed. 
The  camisole  and  safety-sheet  are  employed  only  in  cases  with  desperate 
suicidal  tendencies,  proclivity  to  excessive  masturbation,  great  violence 
and  destructiveness,  and  where  needed  to  keep  in  place  surgical  dress- 
ings, splints,  etc.  In  asylums  mechanical  restraint  has  been  nowadays 
almost  entirely  abandoned. 

Masturbation. — Masturbation  is  more  often  the  consequence  and 
concomitant  of  insanity  than  its  cause.  It  may  be  ameliorated  occa- 
sionally by  drugs  like  bromids,  camphor,  and  lupulin.  Cold  baths  and 
hard  physical  labor  are  more  successful  in  combating  this  habit.  In 
excessive  masturbation,  constant  watching  day  and  night  or  the  use  of 
mechanical  restraint  is  necessary.  The  use  of  blistering  fluids  on  the 
genital  organs  is  only  of  temporary  service.  There  are  instances  in 
which  the  habit  is  so  fixed  and  so  uncontrollable — for  example,  among 
some  imbeciles — that  surgical  interference  would  be  quite  justifiable 
(castration,  clitoridectomy,  ovariotomy,  section  of  the  pudic  nerves, 
ligation  of  the  vas  deferens). 


694  MENTAL  DISEASES. 


CHAPTER  VI. 
MANIA. 

Definition. — Mania  is  a  form  of  insanity  characterized  by  emotional 
exaltation,  acceleration  of  the  flow  of  ideas,  and  motor  agitation.  It  is 
probable  that  the  elated  mood  and  the  hyperexcitation  of  intellectual 
processes  are  both  primary  and  simultaneous  in  their  development. 
The  motor  excitement  results  from  the  conversion  of  the  swiftly  flowing 
ideas  into  acts. 

Etiology. — There  is  no  special  etiology  for  mania — what  has  been 
said  in  the  chapter  on  General  Etiology  has  application  to  this  form.  It 
may  be  said,  however,  that  mania  is  ordinarily  a  disorder  arising  between 
the  twelfth  and  twenty-fifth  years ;  that  it  is  more  common  in  females 
than  in  males ;  that  individuals  of  sanguine  temperament  are  most 
liable  ;  and  that  it  is,  upon  the  whole,  rather  an  infrequent  type  of  in- 
sanity. Hereditary  taint  is  found  in  seventy-five  per  cent,  and  degen- 
erative stigmata  in  twenty  per  cent,  of  cases.  The  percentage  is  larger 
for  the  periodical  form. 

Mental  Symptoms. — An  outbreak  of  mania  is  preceded  by  a 
period  of  depression  lasting  from  a  few  days  to  a  few  weeks,  sometimes 
as  long  as  two  months.  This  prodromal  stage  is  characterized  by  a 
general  feeling  of  malaise,  vague  uneasiness,  and  hypochondriacal  com- 
plaints, accompanied  often  by  headaches,  cephalic  paresthesias,  constipa- 
tion, loss  of  appetite,  sleeplessness,  and  some  loss  of  flesh. 

When  the  true  mental  disorder  begins  to  manifest  itself,  the  sorrowful 
mood  begins  to  give  way  to  an  exalted  condition,  which  the  patient 
looks  upon  as  a  state  of  renewed  health  and  well-being.  He  takes  a 
renewed  interest  in  everything,  and  becomes  unusually  cheerful  and 
talkative.  The  degree  of  increasing  exaltation  varies  much  in  different 
cases.  In  mild  cases  the  patient  begins  to  surprise  his  intimates  by  his 
loquacity,  facetious  remarks,  jocularity,  and  by  his  rather  immoderate 
actions  and  undertakings.  He  enters  upon  many  new  schemes  ;  makes 
innumerable  calls  upon  friends  and  acquaintances  ;  writes  numberless 
letters  ;  purchases  unnecessary  articles  ;  and  is  inclined  to  excessive  in- 
dulgence in  tobacco,  wine,  and  venery.  There  is  considerable  mobility 
or  lability  of  the  emotions,  so  that  the  elation  may  readily  pass  into 
conditions  of  anger  or  tears  over  trifles.  In  more  severe  types  all  of 
these  symptoms  are  aggravated.  A  veritable  chaos  of  ideas  throngs 
through  his  mind,  and  the  effects  upon  movement  of  this  crowding  series 
of  ideas  amount  to  a  constant  motor  agitation.  The  patient  laughs, 
declaims,  sings,  shouts,  makes  grimaces,  dances,  runs  about,  and  becomes 
destructive  and  filthy,  all  inhibitory  idea-associations  ceasing  to  have 
any  influence  over  the  rioting  torrent  of  thought.  In  still  severer 
grades  we  have  the  picture  of  an  acute  delirium,  boisterous  incoherence, 
a  motor  agitation  attaining  to  violent  jactitation,  and  an  actual  and  con- 
siderable increase  of  temperature. 


MA  XI. 1 


695 


Illusions  of  the  special  senses 
The  manias  of  extreme  youth 


The  patient  with  mania  is  fundamentally  optimistic  and  egotistic. 

Everything  about  him  is  rose-colored.  He  feds  rejuvenated  ;  rejoices  in 
his  health,  strength,  and  vitality;  is  delighted  with  the  vivacity  of  his 
ideas  and  the  untrammeled  virility  of  his  intellectual  processes.  His 
general  and  special  sensibilities  are  ordinarily  unaffected  ;  in  only  about 
one-fifth  of  the  cases  are  illusions  and  hallucinations  present,  and  these 
are  almost  always  limited  to  vision.  Occasionally  there  are  illusions 
and  hallucinations  of  taste  and  touch, 
are  more  frequent  than  hallucinations 
or  age  and  alcoholic  mania  are  especially  prone  to  manifest  hallucina- 
tions. Mania  marked  by  the  presence  of  numerous  illusions  and  hallu- 
cinations is  often  designated  as  hallucinatory  mania. 

The  accelerated  flow  of  ideas  in  mania  is  naturally  most  conspicuous 
in  the  speech  of  the  patient,  which  varies  from  garrulity  to  logorrhea. 
In  the  milder  degrees  of  loquacity  we 
are  still  able  to  follow  the  sequence  of 
associations.  The  Sentences  are  often 
bound  together  by  the  ordinary  relation- 
ship and  connections  of  ideas,  but  among 
which  many  latent  ideas  spring  into  con- 
sciousness and  expression ;  and,  again, 
the  sounds  of  words  spoken  suggest 
others  of  similar  sound,  giving  rise  to 
rimes  and  assonances.  Thus,  the  sight 
of  the  physician  may  suggest  drugs,  a 
certain  apothecary,  in  a  special  street, 
in  some  familiar  town  ;  and  the  town 
may  in  turn  give  rise  to  another  series. 
On  the  other  hand,  the  physician's  "How 
do  you  do?"  may  invoke  a  string  of 
assonances  (verbigeration)  commingled 
with  sentences  expressing  their  associ- 
ated ideas — shoe,  two,  new,  grew,  blue, 
crew,  etc.  But  in  the  more  striking 
grades  the  logorrhea  is  so  pronounced 

that  it  is  impossible  to  find  clues  to  any  association,  whether  of  sound 
or  idea.  It  becomes  a  chaos  of  words,  consequent  upon  an  actual  dis- 
sociation of  the  ideas  in  the  rushing  stream  of  thought — a  secondary 
incoherence.  The  entire  loss  of  inhibitory  control  of  ideas  is  especially 
shown  in  the  absolute  lack  of  modesty,  in  the  tendency  to  the  employ- 
ment of  vulgar  and  obscene  words  and  expressions.  This  profanity 
and  obscenity  become  all  the  more  astonishing  by  contrast,  when  it  is 
observed,  as  it  often  is,  even  in  the  most  refined  and  cultured  of  women. 

The  attention  of  the  patient  with  mania  is  extraordinarily  increased, 
so  that  the  most  insignificant  trifle  in  his  environment  does  not  escape 
him.  But  this  very  increase  of  the  power  of  attention,  combined  as  it 
is  with  an  unpausing  stream  of  ideas,  entails  an  absolute  lack  of  con- 
centration. His  attention  can  not  be  held  a  moment.  The  patient's 
memory,  too,  seems  preternaturally  intense,  and  it  is  remarkable  how, 


Fig.  270. — Mania  (puerperal  in  origin). 


696  MENTAL   DISEASES. 

after  recovery,  he  may  remember  all  the  details  of  his  delirious  activity 
with  great  distinctness.  Indeed,  the  patient,  in  the  midst  of  the  chaotic 
turmoil  of  his  mind,  often  recognizes,  as  if  he  stood  apart  from  and 
judged  himself,  the  very  madness  of  his  fancies  and  acts.  The  judg- 
ment-associations are,  in  fact,  normal. 

The  elated  mood  and  rapid  flow  of  ideas  give  rise  to  delusions  of 
expansive  character,  mostly  in  regard  to  strength,  beauty,  and  intel- 
lectual powers,  but  often  also  in  relation  to  wealth,  social  position,  etc. 
In  severe  cases  there  are  the  most  marked  delusions  of  grandeur,  the 
patient  affirming  himself  or  herself  to  be  a  prince,  president,  king, 
queen,  Christ,  the  bride  of  Christ,  the  mother  of  God,  etc.  A  peculiarity 
of  these  affirmations  is  their  transitory  character,  their  impermanence. 
A  patient  will,  in  the  same  breath,  call  himself  a  millionaire,  broker, 
and  king,  and  in  the  next  a  minister  of  the  gospel  and  railroad  magnate. 
If  sharply  told  by  the  physician  to  stop  such  nonsense,  he  will  often 
say  it  was  only  a  joke,  or  he  had  said  such  things  for  fun.  This  shows 
very  well  the  latent  consciousness  of  the  patient  of  the  true  state  of 
affairs. 

The  sexual  instinct  is  morbidly  exalted,  giving  rise  in  both  sexes  to 
immodesty  and  obscenity  of  speech  and  manner,  and  often  to  sexual 
excesses  and  masturbation. 

The  actions  of  patients  with  mania  correspond  in  character  to  the 
degree  of  acceleration  in  the  stream  of  ideas.  When  this  is  very  great, 
turbulence,  violence,  and  destructiveness  are  common,  not  with  any 
homicidal  or  suicidal  intent,  because  they  are  incapable  of  acts  requiring 
any  particular  concentration  of  mind  or  reflection,  but  simply  as  the 
result  of  uncontrollable  automatic  impulsions. 

Sleeplessness  is  characteristic  of  this  condition.  General  sensibility 
appears  to  be  benumbed,  probably  because  of  the  want  of  concentration 
of  thought.  Patients  seem  insensible  to  changes  of  temperature  and  to 
severe  pain.  Such  a  state  often  masks  the  most  serious  disorders,  like 
pneumonia  or  the  pains  of  labor.  I  once  made  an  autopsy  upon 
a  woman  suffering  from  acute  mania  who  died  suddenly.  She  had  been 
for  days  in  the  wildest  uproar  of  mind  and  body.  The  cause  of  death 
was  an  acute  peritonitis  from  rupture  of  a  perforating  duodenal  ulcer. 
The  peritonitis  had  evidently  existed  for  several  days,  yet  this  painful 
affection  had  clearly  had  no  effect  upon  the  course  of  the  mental  and 
motor  symptoms. 

Some  cases  of  mild  maniacal  character  exhibit  a  peculiar  tendency  to 
logically  explain  and  excuse  their  insane  acts,  and  this  type  is  often 
designated  as  reasoning  mania. 

As  already  stated,  mania  begins  with  a  prodromal  stage  of  depression. 
After  the  exalted  stage  has  culminated  and  at  the  beginning  of  conva- 
lescence, a  reactive  stage  of  depression  is  presented,  characterized  by 
irritability,  sensitiveness,  and  lacrymosity.  This  stage  of  depression 
may  be  so  intense  as  to  be  an  actual  melancholia  of  simple  nature  or 
accompanied  with  stupor.  In  instances  of  this  kind  the  possibility  of 
the  patient's  having  a  circular  form  of  insanity,  instead  of  a  simple 
mania,  is  to  be  considered. 


MANIA.  691 

Physical  Symptoms. — Except  in  the  severest  type  of  mania  (acute 
delirium)  the  bodily  temperature  runs  a  normal  course,  sometimes  even 
showing  a  subnormal  character.  In  acute  delirium  the  temperature 
may  reach  104°  or  105°  or  more.  The  pulse  is  small  and  normal, 
or  but  slightly  increased  in  frequency  in  mania.  There  are  no  paraly- 
ses, no  true  anesthesias.  The  absence  of  fatigue  is  often  surprising. 
The  deep  reflexes  are  exaggerated,  as  a  rule.  The  salivary  secretion 
is  frequently  increased.  Perspiration  is  diminished  and  sometimes 
transformed  in  character,  so  as  to  give  a  peculiar  and  often  extremely 
disagreeable  odor  (kakidrosis).  Gastric  disorders  are  nearly  always 
manifested,  and  the  tongue  is  heavily  furred,  frequently  dry.  In 
severe  cases  albuminuria,  propeptonuria,  and  hyalin  cylinders  are 
frequently  found.  The  general  bodily  weight  diminishes  during  the 
progress  of  the  disease,  but  rapidly  increases  with  convalescence.  There 
is  a  corresponding  condition  of  the  appetite,  an  anorexia  during  the 
early  stage  and  until  the  culmination  ;  then  an  increase  of  appetite 
amounting  often  to  bulimia.  The  face  is  sometimes  slightly  suffused, 
but,  as  a  rule,  marked  by  a  yellowish  pallor.  As  the  patient  emaciates 
this  becomes  more  noteworthy,  and  at  the  same  time  the  features 
become  pinched  and  sharp  and  the  eyeballs  sunken.  This  outline  and 
•color  of  the  face,  with  a  tendency  to  dryness  of  the  lips  and  a  heavily 
furred  and  dry  tongue,  are  indications  of  the  progress  of  exhaustion. 

Varieties. — According  to  the  intensity  of  the  manifestations,  upon 
the  basis  of  the  course  of  the  disease,  from  the  nature  of  certain  con- 
comitant symptoms,  and,  fourthly,  in  relation  to  some  of  the  etiological 
factors,  mania  is  frequently  divided  into  several  varieties  bearing  some 
special  qualification.  I  have  already  alluded  to  mild  and  severe  degrees 
of  mania, — mania  mitis,  mania  gravis,  and  acute  delirious  mania, — which 
shade  off  gradually  with  many  intermediate  stages  from  one  into  the 
other.  I  have  also  mentioned  reasoning  and  hallucinatory  mania,  which 
owe  their  names  to  peculiarities  in  the  symptoms.  It  is  customary  to 
speak  also  of  acute,  subacute,  and  chronic  mania,  the  first  two  designa- 
tions referring  especially  to  the  rapidity  or  slowness  of  onset,  the  last 
qualification  to  the  duration  of  the  insanity  in  its  maniacal  form  for  a 
year  or  many  years.  The  word  chronic  does  not  mean  incurable,  for 
cases  of  chronic  mania  of  long  standing  not  infrequently  recover.  The 
term  transitory  mania  was  formerly  employed  to  describe  a  delirious 
condition  of  very  brief  duration,  a  few  hours  or  a  day  or  two,  but  these 
cases  do  not  really  present  the  characteristic  symptoms  of  a  true  mania. 
Periodic  mania  is  a  form  in  which  attacks  of  mania  follow  one  another 
with  perfectly  normal  but  generally  irregular  intervals  of  days,  months, 
weeks,  or  years.  The  attacks  themselves  last  from  a  few  days  to  a  few 
months.  Usually  the  prodromal  depressive  stage  is  absent,  the  culmi- 
nation rapid,  and  convalescence  seldom  marked  by  the  interesting 
depressive  affects  of  ordinary  mania.  The  periodic  attacks  are  very  apt 
to  be  distinguished  by  the  presence  of  special  symptoms,  such  as  a 
reasoning  tendency,  tendencies  to  impulsive  acts,  arson,  stealing,  assaults, 
sexual  and  alcoholic  excesses,  and  to  severe  headaches.  The  longer 
periodic  mania  endures,  the  less  distinct  become  the  normal  features  of 


698 


MENTAL   DISEASES. 


the  intervals.  Recurrent  mania  and  intermittent  mania  are  only  other 
names  for  periodic  mania.  Various  etiological  factors  give  rise  to  such 
designations  as  epileptic,  alcoholic,  morphin,  puerperal,  senile  mania, 
etc.,  in  some  of  which  the  mania  takes  a  special  color  from  its  cause. 
Thus,  the  toxic  manias  are  generally  acute  hallucinatory  conditions. 

Pathology. — The  most  careful  investigations  of  the  central  nervous 
system  have  thus  far  discovered  no  pathologico-anatomical  basis  for 
mania.  The  theory  still  prevails  that  there  is  a  condition  of  congestion 
of  the  higher  brain-centers  underlying  the  manifestations  of  mania,  but 
this  theory  lacks  the  support  of  observed  facts.  We  are,  therefore, 
constrained  to  look  upon  the  disorder  as  functional  in  its  nature,  as  due 
to  a  morbid  change  in  the  nutrition  of  the  cells,  in  the  way  of  deficient 
or  perverted  metabolism. 

Course  of  the  Disease. — Mania  terminates  in  recovery,  death, 
secondary  dementia,  secondary  paranoia,  or  chronic  mania. 

Recovery  takes  place  in  some 
seventy  per  cent,  of  cases.  Some- 
times it  is  exceedingly  rapid,  but 
usually  the  progress  is  gradual  and 
rhythmical  to  the  normal  state.  This 
rhythm  is  a  sort  of  oscillation  be- 
tween good  and  bad  days,  but  with 
constant  improvement.  Occasion- 
ally the  patient  improves  steadily 
and  uninterruptedly  until  recovered. 
Recovery  is  sometimes  not  perfect, 
so  that  we  speak  of  it  as  recovery 
with  defect. 

Death  takes  place  in  but  five  per 
cent  of  cases.  The  cause  of  death 
is  sometimes  exhaustion,  as  in  acute 
delirium  ;  more  often  an  intercurrent 
affection,  such  as  pneumonia,  neph- 
ritis, and  the  like.  Heart  disease 
and  alcoholism  add  greatly  to  the 
danger  of  lethal  termination. 

Dementia  is  the  result  of  the 
disorder  in  about  one-tenth  of  the 
cases.  The  degree  of  dementia 
varies  from  a  slight  diminution  in  some  of  the  higher  qualities  and 
powers  of  the  mind  to  pronounced  mental  enfeeblement  with  vestiges 
of  the  antecedent  mania  and  complete  confusion  and  incoherence.  The 
vestiges  of  the  antecedent  mania  are  commonly  in  the  form  of  motor 
agitation,  and  occasionally  hallucinations  and  rudimentary  delusions  of 
exalted  character. 

A  paranoia  secondary  to  mania  is  met  with  in  rare  instances,  perhaps 
once  among  a  hundred  cases.  In  such  termination  we  observe  a  tendency 
to  the  systematization  of  some  of  the  original  maniacal  delusions. 

Chronic  mania  is  quite  as  rare  a  condition  as  secondary  paranoia.    By 


Fig.  271. — Chronic  mania. 


MANIA.  699 

this  term  is  meant  a  continuance  of  the  typical   maniacal  symptoms  for 
a  long  period  of  time — a  year  or  many  years. 

It  must  be  remembered,  too,  thai  an  attack  of  acute  or  subacute 
mania  may  be  merely  the  beginning  of  a  periodic  mania  or  of  a  circular 
insanity. 

Diagnosis. — One  must  be  careful  not  to  confound  delirium  from 
fever  with  an  attack  of  acute  mania.  Except  in  acute  delirious  mania,  the 
absence  of  fever  in  the  mental  disorder  should  be  distinctive.  The  three 
cardinal  symptoms  of  mania  should  be  kept  constantly  in  mind — viz., 
the  exalted  mood,  the  accelerated  flow  of  ideas,  and  the  motor  excitement. 
We  must  determine  whether  these  are  primary  or  secondary  to  halluci- 
nations and  delusions,  and  whether  the  syndrome  is  complicated  by 
other  conditions,  such  as  general  paralysis  and  alcoholism.  A  very 
mild  degree  of  mania  may  pass  unrecognized,  unless  it  is  possible  to 
diagnose  it  from  a  pronounced  change  in  the  character  of  the  individual 
and  from  the  accompanying  insomnia.  The  physical  symptoms  and 
the  defect  of  intellect  should  suffice  to  distinguish  the  exalted  stage  of 
general  paresis  from  an  acute  mania.  The  delusions,  too,  of  paresis 
have  a  peculiar  monstrosity  of  character  that  differentiates  them  from 
the  exalted  ideas  of  the  maniac.  Sometimes,  however,  there  will  be 
difficulty  in  making  a  speedy  diagnosis  between  these  two  analogous 
exalted  conditions. 

In  acute  hallucinatory  paranoia  we  may  encounter  the  three  emo- 
tional symptoms  of  acute  mania,  but  on  examination  these  will  be 
found  not  to  be  primary  in  their  origin,  but  secondary  to  the  hallucina- 
tions. In  the  epileptic  type  of  acute  hallucinatory  paranoia  defects  of 
memory  are  distinctive. 

Subacute  types  of  mania  may  resemble  congenital  states  of  mental 
weakness,  in  so  far  as  excesses,  moral  delinquencies,  etc.,  are  concerned. 
Here,  too,  intellectual  defect  and  the  early  history  will  serve  to  differ- 
entiate the  condition  of  congenital  feeble-mindedness. 

We  can  never  determine  from  a  single  attack  whether  we  have  before 
us  a  form  of  periodic  mania  or  circular  insanity.  It  is  only  the  suc- 
cession of  outbreaks  and  the  cyclical  character  that  can  serve  us  here. 

Prognosis. — Some  of  the  prognostic  data  are  apparent  from  what 
has  gone  before.  In  the  main  the  outlook  is  favorable,  since  so  large 
a  percentage  of  the  cases  recover.  After  six  months  have  passed  the 
prognosis  becomes  only  half  as  good,  and  after  two  or  three  years  is 
quite  unfavorable.  There  are  exceptional  instances  of  recovery  after 
many  years.  The  younger  the  patient,  the  better  the  chance  for  cure.  A 
second  or  third  attack  may  be  recovered  from  completely,  if  they  be 
merely  recedival  attacks ;  but  if  they  indicate  a  periodic  insanity,  the 
outlook  is  unpromising. 

Treatment. — What  has  already  been  said  in  the  chapter  on  General 
Treatment  is  applicable  here.  The  requisite  isolation  and  supervision 
of  a  patient  with  acute  mania  can  seldom  be  satisfactorily  accomplished 
outside  of  an  asylum,  unless  his  means  are  sufficient  to  secure  the  needed 
nurses  and  suitable  surroundings. 

Rest  in  bed  aids  in  the  prevention  of  exhaustion,  and  renders  super- 


700  MENTAL  DISEASES. 

vision,  care,  and  feeding  more  easy.  To  induce  sleep  and  allay  motor 
excitement,  hydrotherapy  and  the  hypodermatic  use  of  hyoscin,  hyoscy- 
amin,  or  duboisin  are  extremely  valuable.  In  mild  cases,  equal  parts 
of  trional  and  sulphonal  are  preferable  to  the  drugs  just  mentioned. 
Paraldehyd  is  also  an  excellent  hypnotic  for  mild  cases. 

Overfeeding  is  also  an  extremely  important  indication.  Liquid  and 
easily  digested  foods  are  to  be  recommended.  The  bowels  should 
always  be  regulated.  Brandy  is  added  to  the  liquid  food  when  ex- 
haustion is  imminent,  but  otherwise  stimulants  are  contraindicated. 
Should  there  be  danger  of  collapse,  the  repeated  hypodermatic  injections 
of  ordinary  salt  and  water  (ten  to  fourteen  ounces)  over  the  abdomen 
or  in  the  thigh  are  valuable.  In  the  depressed  period  of  convalescence 
small  doses  of  opium  are  often  useful. 


CHAPTER  VII. 
MELANCHOLIA, 

Definition. — Melancholia  is  a  mental  disorder  characterized  by  a 
primary  depressed  mood  associated  with  retarded  flow  of  thought,  and 
either  motor  inhibition  or,  in  some  instances,  with  an  agitation  expres- 
sive of  anxiety  and  apprehension. 

Etiology. — Heredity  is  encountered  in  fully  one-half  of  the  cases. 
Inheritance  of  the  same  form  of  psychosis  is  strikingly  frequent  as 
regards  melancholia.  Females  are  more  often  affected  than  males, 
almost  in  the  proportion  of  two  to  one.  Heredity,  physical  ill-health, 
and  mental  stress  together  form  a  triad  of  factors  which  are  responsible 
for  most  cases  of  melancholia.  This  psychosis  is  observed  at  any  age. 
At  puberty  it  is  commonly  associated  with  excessive  masturbation. 
Love-affairs,  with  the  novel  stresses  incident  to  such  emotions,  may  be 
an  exciting  cause  in  adolescence.  Pregnancy,  especially  in  primiparse, 
is  a  not  infrequent  cause,  owing  to  the  emotional  strains  which  are  fre- 
quently clustered  about  this  physiological  commotion.  The  melancholia 
of  pregnancy  generally  begins  about  the  third  or  fourth  month.  Pro- 
longed lactation  may  cause  melancholia  by  inducing  a  general  debility 
and  anemia.  The  parturitional  period  of  the  puerperal  state  does  not 
produce  melancholia  so  often  as  gravidity  and  lactation.  The  psychoses 
of  parturition  are  more  commonly  of  the  nature  of  acute  hallucinatory 
paranoia.  The  melancholia  of  the  climacteric  is  due  to  the  physiological 
commotion  incident  to  this  period  of  involution  and  to  associated  ill- 
health  and  mental  strains.  In  old  age  melancholia  is  often  associated 
with  senile  involution  and  nutritional  changes  in  the  central  nervous 
system  from  cerebral  endarteritis.  Homesickness  is  a  frequent  cause  of 
melancholia.     Auto-intoxication  undoubtedly  plays  a  considerable  rdle 


MELANCHOLIA. 


7<>] 


in  the  development  of  melancholia.  Occasionally  severe  forme  of  agi- 
tated melancholia  are  associated  with  chronic-  alcoholism.  Ii  is  said 
that  northern  races  and  people  inhabiting  mountainous  regions  are 
especially  subject  to  melancholia. 

Mental  Symptoms. — The  affective  state  in  this  psychosis  varies 
from  simple  dejection,  in  which  every  thought  and  everything  in  the 
environment  of  the  patient  has  a  sorrowful  color,  to  a  state  of  profound 
depression,  in  which  the  patient  is  either  paralyzed   by  the  dreadful 
nature  of  his  concepts  or  thrown  into  a  state  of  agitated  suffering  asso- 
ciated with  marked  precordial  distress.     There  arc  many  degrees  lying 
between   these  extremes.     This   morbid  depression    is   in   many   ways 
paralleled  by  and  analogous  to  the  conditions  of  normal  grief  in  which 
we  observe  a  varied  behavior  of  different  individuals  under  the  influence 
of  distressing  emotions  ;  some  become  strangely  quiet  and  still ;  others, 
again,  make  noisy  and  agitated  demonstrations  of  their  grief.     Normal 
grief,  too,  is  often  accompanied  by  sensations 
of  choking  and  of  sinking  at  the  heart,  which 
are  similar  but  comparatively  mild  manifes- 
tations of  the  precordial  anxiety  and  dread 
of   the    psychosis.      We   observe    often    in 
melancholia  a  rhythmic   oscillation  of  the 
state  of  depression  during  the  day,  and  fre- 
quently from  one  day  to  another.     Thus, 
the  depression  is  at  its  height  in  the  morn- 
ing   (when    suicidal    tendencies    not    infre- 
quently present  themselves),  being  followed 
by   a   recession   with   another   exacerbation 
toward   night.     Very   often   patients   sleep 
better    on    alternate    nights,   and    manifest 
intenser  emotional  depression    on  alternate 
days.     In  some  cases,  presenting   what  is 
known  as  the  apathetic  form  of  melancholia, 
the   patients   complain  that   they   have    no 
feeling  at  all ;  that  they  are  affected  neither 
by  things  cheerful  nor  grievous,  pleasant  nor  painful ;  that  they  have 
no  longer  any  love  for  family  or  home,  or  interest  in  anything ;    that 
they  can  never  be  sad  or  glad  again.     Sensory  disturbances  are  often 
absent.     In   the   apathetic  variety  there   may  be  analgesia.     Marked 
illusions  and  hallucinations  are  observed  in  only  about  a  tenth  of  all 
cases  of  melancholia.     Where  they  are  present  in  great  number,  the 
psychosis  is  designated  as  acute  hallucinatory  melancholia.     The  pares- 
thesias in  the  region  of  distribution  of  the  vagus  are  neither  illusions 
nor  hallucinations,  but  they  may  give  rise  to  delusions  ;  they  depend 
probably  upon  vasomotor  disturbances.      The  melancholiac  perceives 
and  identifies  ordinary  and  special    sensations  slowly  and  with  diffi- 
culty.     The    peripheral     stimuli    of   his    environment    go    unnoticed. 
When  hallucinations  are  present,  they  usually  affect  most  of  the  senses, 
and  are  terrifying  and  dreadful  in  character.     The  patient   sees  the 
flames  of  hell,  phantoms,  and  ghosts  of  dead  persons  ;  hears  voices  which 


Fig.  272. — Acute  melancholia 
passiva. 


702  MENTAL   DISEASES. 

reproach  and  threaten  him,  or  the  sounds  of  machinery  and  other 
tortures  which  are  being  prepared  to  cut  him  up  or  mutilate  him  ;  smells 
and  tastes  horrible  things,  and  so  on. 

Next  to  the  affect  of  depression,  the  most  noteworthy  symptom  of 
melanjholia  is  the  slowing  of  the  thought  processes.  This  is  the  an- 
tithesis of  the  accelerated  flow  of  thought  noted  in  maniacal  conditions. 

The  processes  of  memory  are  retarded,  and  the  attention  of  the 
patient  difficult  to  gain.  A  minute  or  several  minutes  are  required  for 
the  answer  to  the  simplest  question.  Sometimes  no  answer  is  given  at 
all,  or  at  most  the  lips  stir  inaudibly. 

The  contents  of  the  concepts  may,  in  milder  degrees,  show  no  de- 
lusions. More  often  the  patient  attempts  to  explain  his  feeling  of 
abject  misery  and  distress  either  by  the  presence  of  some  fancied  physi- 
cal ailment  (hypochondriacal  melancholia,  with  delusions  of  having 
syphilis,  consumption,  cancer,  impotence,  incurable  disorders  of  the 
stomach,  bowels,  etc.),  or  as  the  result  of  some  sin  of  his  past  life.  To 
the  delusion  of  having  sinned  an  especial  color  is  given  by  the  character 
of  the  patient's  early  education.  Thus,  a  strong  religious  bias  gives  rise 
to  delusions  of  having  committed  the  unpardonable  sin,  of  being  doomed 
to  hell,  to  everlasting  punishment,  to  be  buried  alive,  etc.  Often  such 
delusions  are  connected  with  some  trivial  error  of  his  past  life.  For 
instance,  a  patient  of  mine  recently  told  me,  "  I  once  chloroformed  a 
dog  to  death  and  buried  him.  I  think  now  I  made  a  mistake  in  not 
making  positively  sure  that  the  dog  was  dead,  and  as  a  result  I  am 
doomed  to  be  buried  alive  also,  and  to  be  tortured  with  dreadful 
thoughts  through  eternity,  each  day  the  torture  growing  more  dreadful, 
up  to  the  decillionth  power  of  intensity." 

Patients  often  say  they  are  not  sick,  they  are  only  wicked.  They 
have  committed  sins  not  only  against  God,  but  against  society.  Not 
only  must  they  undergo  the  punishment  ordained  by  Heaven,  but  they 
must  answer  to  man  for  infringements  of  human  law.  They  are  to  •  be 
put  in  prison,  to  be  killed,  to  be  hung.  Thus  they  come  to  delusions 
which  are  somewhat  similar  to  persecutory  ideas  in  that  they  believe  the 
officers  of  the  law  are  after  them,  etc.  These  differ,  however,  from  the 
true  persecutory  delusions  in  which  patients  have  no  self-depreciatory 
ideas,  but  believe  themselves  to  be  the  innocent  victims  of  inimical  con- 
spiracies. Delusions  of  poverty  are  very  common,  and  especially  so  in 
senile  melancholia. 

The  conduct  of  the  melancholiac  depends  upon  the  contents  of  his 
consciousness.  In  his  expression  we  note  the  lines  of  extreme  depres- 
sion, or  of  fear  and  terror.  The  patient  with  the  delusion  of  sin  or 
poverty,  for  example,  presents  motor  inhibition.  He  sits  in  one  place 
with  head  bowed  down,  unmindful  of  what  goes  on  about  him,  indiffer- 
ent or  apathetic  to  all  questions  put  to  him,  resisting  every  attempt  to 
give  him  food  or  medicine,  or  to  dress  and  undress  him,  or  to  give  him 
exercise.  He  is  lost  in  the  contemplation  of  his  misery.  Another 
patient,  with  these  or  similar  depressed  ideas  more  accentuated,  or  with 
marked  hallucinations,  will  wring  his  hands,  tear  his  hair,  walk  or  run 
up  and    down,  bewailing    his  misfortunes,  or    seeking  to    escape    the 


MELANCHOLIA. 


703 


dreadful  fate  in  store  for  him.  In  the  first  case  the  motor  inhibition 
may  be  so  complete  as  to  make  the  patient  perfectly  immobile,  so  that 
not  a  single  voluntary  movement  is  made  ;  even  micturition  and  defeca- 
tion are  involuntary.  Such  immobility  la  generally  of  flaccid  character, 
but  sometimes  it  assumes  the  phase  of  rigidity,  a  waxy  flexibility,  or  a 


Fig.  273. — Catatonic  symptoms  in  various  psychoses  (melancholia,  general  paresis,  circular  insanity, 
primary  dementia,  etc.)  (photograph  loaned  by  Dr.  Atwood,  of  Bloomingdale). 


spasmodic  resisting  rigidity  (catatonic  rigidity).  Catatonic  symptoms 
have  been  noted  in  other  forms  of  psychoses,  but  the  disorder  described 
by  Kahlbaum  under  the  name  catatonia  is  really  a  form  of  melancholia. 
Suicidal  tendencies  are  observed  in  every  type  of  melancholia,  but  es- 
pecially in  those  with  precordial  distress  and  agitation.      In  the  milder 


704 


MENTAL  DISEASES. 


degrees,  an  attempt  at  suicide  is  often  the  first  intimation  to  friends  of 
the  actual  existence  of  insanity,  since  in  these  cases,  outside  of  the  sor- 
rowful mood  of  the  patient,  the  intellectual  processes  may  go  on  as 
before.  Cases  of  melancholia  attonita  (with  marked  motor  inhibition) 
also  often  make  attempts  at  suicide,  unexpected  explosive  attempts,  the 
result  of  the  sudden  letting  up  of  mental  and  bodily  tension.  This  has 
been  called  the  raptus  melancholicus.  Homicidal  attempts  and  violent 
assaults  are  occasional  in  melancholia.  A  melancholy  mother  kills  her 
children  to  put  them  out  of  an  unhappy  world.  Or  a  sudden  dangerous 
assault  is  made  as  an  explosion  of  motor  tension.  Hypochondriacal 
melancholiacs  may  mutilate  themselves.  Patients  with  melancholia 
have  also  been  known  to  enter  upon  alcoholic  excesses  to  drown  their 
misery  ;  this  is  especially  observed  in  periodical  melancholia.  The  re- 
fusal of  food  is  almost  the  rule  of  conduct  in  all  forms  of  melancholia. 
Sometimes  this  refusal  rests  upon  a  delusional  foundation  :  the  patient 

thinks  he  can  not  digest  his  food,  that  it 
never  passes  through  him,  that  he  is  too 
poor  to  pay  for  it,  that  he  is  too  wicked  to 
eat,  that  he  must  do  penance,  and  so  on. 
Or  he  refuses  food  with  deliberate  suicidal 
intent.  Generally,  profound  anorexia,  con- 
stipation, and  gastro-intestinal  disorders  are 
at  the  basis  of  this  refusal  to  eat. 

Physical  Symptoms. — The  pulse  is 
usually  subnormal  in  frequency,  though 
sometimes,  especially  in  agitated  forms,  ac- 
celerated. The  peripheral  arteries  are  con- 
tracted and  the  extremities  cold.  The  res- 
piration is  retarded  and  superficial,  as  a 
rule,  though  it  may  be  increased  in  the 
agitated  types.  Sleep  is  much  disordered, 
and  even  altogether  absent,  in  severe  cases. 
The  patient  emaciates  both  through  refusal 
of  food  and  because  of  disordered  digestion. 
The  gastric  juice  and  saliva  are  often  diminished  in  quantity.  The 
tongue  is  foul  and  furred,  and  obstinate  constipation  is  present.  As  a 
result  of  constipation,  elevations  of  temperature  may  be  observed,  but 
otherwise  the  temperature  is  undisturbed.  The  surface  temperature  in 
the  extremities  is  often  much  reduced.  Amenorrhea  is  frequently  in- 
duced by  melancholia  as  well  as  by  mania. 

Varieties. — As  in  the  case  of  mania,  we  distinguish  acute,  subacute, 
and  chronic  forms  of  melancholia ;  acute  and  subacute  according  to  the 
degree  and  rapidity  of  inception,  chronic  from  the  duration. 

Melancholia  passiva  is  a  term  used  to  describe  the  cases  with  great 
motor  inhibition  of  the  flaccid  order. 

Melancholia  attonita  designates  the  type  with  motor  tension  and 
rigidity. 

Melancholia  agitata  is  a  name  used  for  melancholia  with  motor 
excitement. 


Fig.  274. — Chronic  melancholia 
passiva. 


MELANCHOLIA.  705 

Acute  hallucinatory  melancholia  i-  the  form  accompanied  by  numerous 

illusions  and  hallucinations. 

Hypochondriacal  melancholia  is  melancholia  associated  with  delusions 
as  to  physical  maladies. 

Raptus  melancholias  is  a  phrase  employed  to  describe  the  furious 
outbreaks  of  violence  toward  the  patient  himself  or  others,  on  the 
sudden  cessation  of  mental  and  motor  tension. 

Catatonic  melancholia,1  already  alluded  to,  is  not  a  distinct  type  of 
mental  disease,  but  simply  a  modification  in  the  course  of  melancholia. 
It  has  often  been  considered  as  a  special  form  of  psychosis,  and  many 
alienists  have  argued  pro  and  con.  the  question  of  its  being  a  clinical 
entity.  It  is  a  very  rare  syndrome.  A  perfectly  typical  case  is  the 
following,  observed  by  me  in  the  Hudson  River  State  Hospital  : 

Case  I. — B.  R.,  female;  age  thirty-one;  married,  with  four 
children;  Hebrew;  common  education;  born  in  United  States; 
admitted  to  the  Hudson  River  State  Hospital  in  February,  1884  ;  no 
heredity. 

The  first  evidence  of  mental  disturbance  was  in  August,  1883,  after 
the  birth  of  her  last  child,  which  she  nursed  for  two  months,  when  she 
became  sleepless,  restless,  and  inclined  to  refuse  food.  Soon  she  devel- 
oped the  idea  that  she  would  never  recover,  began  to  bemoan  her  con- 
dition, and  said  it  was  hard  to  die  so  young.  There  was  complete 
anorexia.  She  took  no  interest  in  anything,  became  careless  of  her 
person  and  dress  and  negligent  of  everything  in  which  she  had  formerly 
been  interested.  Three  weeks  before  admission  she  became  suicidal, 
spoke  of  it,  and  attempted  to  choke  herself  and  to  cut  herself  with  glass. 
She  would  bite  her  caretakers,  and  took  every  means  possible  to  make 
away  with  herself.  Her  menstruation  was  regular.  There  was  con- 
siderable constipation.  The  case  was  regarded  as  one  of  puerperal 
melancholia. 

February  11th,  two  days  after  admission,  she  tried  to  beat  her  head 
against  the  bedstead  ;  said  some  one  was  killing  her  children  and  putting 
them  in  a  box  ;  said  arsenic  was  put  in  her  coffee  and  that  her  mother 
was  in  the  asylum ;  was  sleepless  and  had  to  be  fed  forcibly.  She 
became  rapidly  worse  during  the  next  few  days ;  went  into  a  condition 
of  noisy  excitement,  calling  for  her  mother,  whom  she  believed  to  be  in 
the  building ;  mentioned  her  delusions  of  poisoning,  beat  and  bruised 
herself  against  the  bedstead,  and  refused  all  food.  She  was  very  suicidal. 
Her  mouth  and  tongue  became  dry;  she  showed  symptoms  of  exhaustion 
and  was  fed  with  the  tube  for  a  considerable  period.  She  continued  to 
refuse  food,  to  resist  all  care  strenuously,  and  to  be  desperately  suicidal 
until  March  15th,  when  she  became  cataleptic,  with  marked  nexibilitas 
cerea ;  absolutely  silent ;  noticing  nothing,  not  even  her  husband,  who 
visited  her ;  would  swallow  food  put  in  her  mouth  ;  made  no  voluntary 
motions  ;  pulse  good  ;  bowels  moved  by  enemata,  but  began  to  wet  and 
soil  the  bed,  and  as  she  grew  stronger  was  looked  upon  as  rapidly  be- 
coming demented.     This  state  of  catalepsy  continued,  with  variations 

1  "Catatonia,"  by  Frederick  Peterson,  M.D.,  and   Charles  H.  Langdon,  M.D., 
"  Proceedings  of  the  Amer.  Medico-Psychological  Assoc. ,"  Baltimore,  1897. 
45 


706  MENTAL  DISEASES. 

from  time  to  time,  for  a  month  or  more,  when  she  began  to  be  destruc- 
tive of  her  clothing,  would  strip  herself  naked,  and  was  filthy  in  her 
habits.  She  remained  in  that  condition,  seldom  uttering  a  word  for 
months,  until  about  the  last  of  November,  1884,  when  she  began  to  cry 
out  loudly,  "  Bring  me  home  to  my  children  in  New  York.  Bring 
me  home  to  my  children  in  New  York,"  reiterating  this  over  and  over 
from  morning  until  night,  and  accompanying  the  phrase  with  rhythmic 
movements  of  the  hands  and  arms  as  if  she  were  waving  them  in  the 
direction  she  wished  to  go.  There  was  a  rhythm  in  the  days,  too,  for 
every  alternate  day  she  was  quiet  in  her  chair  and  would  whisper.  This 
continued  without  variation  for  some  two  months,  during  all  of  which 
time  she  was  eating  and  sleeping  well  and  gaining  in  flesh. 

About  the  middle  of  January,  1885,  her  verbigeration  took  another 
character,  the  gesticulations  remaining  the  same.  She  began  to  recite 
all  day  long,  every  other  day,  with  great  rapidity  and  with  infinite 
variation,  in  rimes  of  unintelligible  words,  as  follows : 

"Moccasins,"  "Tabies,"  "Jobis," 

"Voccasins,"  "Gabies,"  "Chobis," 

' '  Doccasins, "  "  Habies, "  "  Sobis, ' ' 

' '  Crockasins, "  "  Sabies, "  "  Pobis, ' ' 

' '  Lockasins,  "  "  Labies, "  "  Tickater, ' ' 

' '  Tockasins, "  "  Mabies. "  "  Fickater, ' ' 

' '  Jockasins, "  "  Kabies, "  "  Sickater, ' ' 

' '  Hockasins, "  "  Nobis, "  "  Lickater, ' ' 

' '  Babies, "  "  Gobis, "  "  Mickater, ' ' 

and  so  on,  ad  infinitum.  She  only  changed  to  another  word  when  the 
possibilities  of  rime  were  exhausted. 

She  was  mentally  confused.  When  asked  why  she  made  these 
rimes  she  said  some  one  told  her  to ;  but  this  was  probably  an  answer 
given  because  she  could  not  explain  why,  for  she  had  now  no  hallucina- 
tions or  delusions.  She  was  so  confused  that  she  did  not  feel  sure  it 
was  her  husband  who  came  to  see  her. 

A  few  months  later  she  gave  up  the  riming  assonances  and  returned 
to  the  old  phrase,  with  occasional  variations,  "  I  want  to  go  home  to  my 
children  in  New  York."  "  Won't  I  be  glad  when  I  get  home  to  my 
children  in  New  York."  "  What  good  times  I'll  have  when  I  get 
home  to  my  children  in  New  York  ...  to  my  cosy  home  in 
New  York  .  .  .  when  I  get  into  the  car  which  takes  me  to  my 
husband  and  children  in  New  York."  This  was  the  refrain  for  many 
months  on  alternate  days,  accompanied  as  before  with  rhythmic  gestures 
of  both  arms  in  the  supposed  direction  of  New  York.  In  the  spring  of 
1886,  on  the  quiet,  alternate  days,  she  began  to  sew.  She  steadily  im- 
proved in  flesh  and  was  looked  upon  as  in  a  state  of  dementia.  There 
was  no  appreciable  change  in  her  condition  during  the  summer.  The 
verbigeration  and  gesticulation  alternated  with  quiet  and  industrious 
days  until  the  autumn  of  1886,  when  improvement  began  to  manifest 
itself  in  every  way,  and  in  November  she  was  discharged  as  improved 
and  went  home  with  her  husband  on  trial.  There  she  recovered  per- 
fectly so  that  not  a  vestige  of  the  insanity  remains,  and  she  is  to  this  day 


MELANCHOLIA.  707 

in  full  charge  of  her  household  and  family,  as  reported  to  us  not  long 
since  by  her  husband. 

In  this  case  we  have,  first,  an  ordinary  suicidal  melancholia,  with 
delusions  of  poisoning,  the  killing  of  her  children,  etc.,  and  hallucina- 
tions of  taste  and  hearing,  and  possibly  sight,  rapidly  becoming  an 
aggravated  case  of  melancholia  agitata  of  almost  maniacal  character, 
with  a  sudden  lapse  into  a  cataleptic  condition  lasting  about  a  month, 
after  which  she  was  for  some  months  silent,  stupid,  having  to  be  dressed, 
undressed,  and  cared  for  in  every  way,  when  she  began  to  show  symp- 
toms of  verbigeration  and  rhythmic  gestures  previously  described. 
During  most  of  the  long  period  presenting  these  symptoms  she  was 
mentally  confused,  but  her  mood  was  rather  cheerful.  She  would  fre- 
quently smile  when  any  one  asked  her  why  she  talked  in  that  way, 
and  she  seemed  to  take  pleasure  in  what  she  was  constantly  reiterating. 

The  conclusions  at  which  we  arrived  in  our  paper  were  as  follows : 
I.   Catatonia  is   not  a  distinct  form  of  insanity — not  a  clinical 
entity. 

II.  There  is  no  true  cyclical  character  in  its  manifestations  ;  hence 
it  can  not  properly  be  classed  as  a  form  of  circular  insanity. 

III.  It  is  simply  a  type  of  melancholia. 

IV.  It  is  not  desirable,  therefore,  to  retain  the  name  catatonia. 

V.  The  term  "  catatonic  melancholia  "  or  "  catatonic  syndrome  " 
may  be  usefully  retained  as  descriptive  of  melancholia  with  cataleptic 
symptoms,  verbigeration,  and  rhythmic  movements,  but  should  be 
strictly  limited  to  this  symptom-complex. 

VI.  The  prognosis  in  melancholia  with  catatonic  symptoms  is  more 
grave  than  in  any  other  form. 

VII.  The  treatment  of  the  catatonic  syndrome  is  the  same  as  for  the 
other  types  of  melancholia. 

Periodical  or  intermittent  or  recurrent  melancholia  has  about  the  same 
significance  as  the  similar  designation  of  forms  of  mania. 

Other  names  are  frequently  given  to  melancholia,  such  as  senile, 
puerperal,  and  the  like,  but  they  merely  cite  some  determining  factor. 
The  fundamental  condition  is  the  same. 

Pathological  Anatomy. — As  is  true  of  mania,  there  is  also  no 
known  pathological  anatomy  for  melancholia.  It  is  a  functional  nutri- 
tional disorder  of  the  brain,  a  diminished  or  perverted  metabolism, 
supposed,  theoretically,  to  rest  upon  a  cerebral  anemia,  or,  possibly,  an 
autotoxemia. 

Course  of  the  Disease. — There  is  no  such  distinct  prodromal  stage 
in  melancholia  as  in  mania.  The  period  of  invasion  is  deliberate,  and 
the  symptoms  chiefly  manifested  at  first  are  gastro-intestinal  disorders, 
dyspepsia,  loss  of  appetite,  constipation,  accompanied  by  sensations  of 
pressure  in  the  head  or  headache,  insomnia,  and  general  malaise.  The 
depression  itself  is  the  cardinal  early  psychic  symptom.  Melancholia, 
like  all  psychic  disorders,  is  slow  in  its  progress,  and  runs  a  course  of 
from  three  to  six  months  in  the  most  favorable  cases,  but  sometimes  a 
year  or  two  or  three  elapse  before  recovery  takes  place.  Ordinarily, 
recovery  is  gradual,  and  is  frequently  accompanied  by  a  species  of  reactive 


708  MENTAL  DISEASES. 

exaltation.  Occasionally  recovery  is  quite  rapid.  In  women  the  ap- 
proach of  convalescence  is  indicated  by  a  return  of  the  menstrual  func- 
tion. In  all  cases  improvement  in  physical  health  accompanies  conva- 
lescence. 

Melancholia  terminates  in  recovery  (ninety  per  cent.),  in  recovery 
with  defect,  in  death,  in  secondary  dementia,  in  chronic  melancholia,  or 
in  a  secondary  paranoia. 

While  the  majority  of  cases  of  melancholia  recover  completely,  there 
are  a  few  in  which,  despite  apparent  recovery,  accurate  investigation 
reveals  a  defect  of  the  intellectual  powers,  a  difficulty  of  entertaining 
complicated  conceptions  and  judgments,  which  may  easily  escape  the 
notice  of  the  patient's  friends.  In  a  very  small  number  of  cases  the 
mind  becomes  so  enfeebled  that  the  condition  becomes  a  veritable 
secondary  dementia,  in  which  we  discover  vestiges  of  the  antecedent 
melancholia  in  the  shape  of  automatic  phrases  and  movements  and 
expressions  of  a  depressed  color,  yet  without  any  actual  affective  mood. 
The  patients  become  negligent  of  person  and  dress  in  the  extreme,  even 
filthy  in  their  habits. 

A  chronic  persistence  of  the  melancholic  symptoms  is  rather  more 
frequent  as  a  termination  than  secondary  dementia.  In  chronic  melan- 
cholia we  observe  symptoms  of  either  the  simple  depressed  or  the  agitated 
form  with  which  the  disorder  began,  but  these  symptoms  are  diminished 
in  intensity.  The  precordial  distress  disappears.  Some  of  their  delu- 
sions, movements,  and  verbal  expressions  become  automatic,  as  in  cases 
accompanied  by  dementia.  Special  forms  of  chronic  melancholia  are 
the  insanity  of  negation  and  insanity  with  transformed  or  duplicated  per- 
sonality.    These  are  very  apt  to  develop  upon  a  hypochondriacal  basis. 

A  termination  of  melancholia  in  a  paranoid  condition  (paranoia 
secondaria  melancholica)  while  rare,  is  rather  more  frequent  as  a  sequel 
of  melancholia  than  of  mania.  In  these  cases  there  are  numerous 
hallucinations,  and  a  cluster  of  delusions,  religious,  persecutory,  or  hypo- 
chondriacal, which  gradually  become  systematized  to  a  greater  or  less 
degree.  About  half  of  such  cases  recover  ultimately,  the  remainder 
passing  into  a  condition  of  dementia. 

Death  in  cases  of  melancholia  is  due  to  suicide,  marasmus,  visceral 
disorders,  diarrhea,  pneumonia,  etc.  A  very  large  number  of  long- 
standing cases  die  of  tuberculosis. 

Diagnosis. — One  of  the  most  common  conditions  with  which  melan- 
cholia may  be  confounded  is  a  depressed  stage  of  general  paresis.  The 
chief  points  of  distinction  are  the  actual  intellectual  defect  nearly 
always  demonstrable  in  paralytic  dementia,  and  especially  the  physical 
symptoms  of  paresis,  pupillary  changes,  faciolingual  tremor,  character- 
istic speech,  greatly  exaggerated  or  lost  deep  reflexes,  and  one-sided 
facial  weakness.  The  depression  of  the  paralytic  dement  is  superficial. 
His  melancholy  delusions  are  ordinarily  distinguished  by  their  inordinate 
and  preposterous  character,  by  the  monstrosity  of  their  contents.  In 
addition  to  these  points,  the  signs  of  previous  syphilis  and  the  age  from 
thirty-five  to  fifty  years  would  have  some  corroborative  value  in  the 
diagnosis  of  general  paresis. 


MELANCHOLIA.  TO!) 

A  primary  dementia  may  be  misinterpreted  ae  a  stuporous  form  of 
melancholia.  In  primary  dementia,  intellectual  defect  is  the  cardinal 
symptom  ;  in  apathetic  melancholia  there  is  no  intellectual  defect,  and 
the  apathy  is  often  clearly  accompanied  by  painful  affects  from  time  to 
time. 

Hallucinatory  paranoia  with  depressive  hallucination-  may  be  con- 
fused with  melancholia.  In  hallucinatory  paranoia  we  have  two  vari- 
eties, a  stuporous  and  an  agitated  form,  and  these  have  some  analogy 
to  melancholia  attonita  and  melancholia  agitata.  The  want  of  fixity 
and  systematization  of  delusions  in  melancholia  is  to  be  remembered. 
The  history  of  the  patient  will  often  reveal  whether  the  depression  is 
primary  or  not.  But  the  differentiation  is  often  difficult,  and  especially 
so  between  hallucinatory  melancholia  and  hallucinatory  paranoia.  Long 
and  careful  study  of  the  case  during  its  progress  may  be  requisite  for 
an  absolute  diagnosis. 

Senile  dementia  may  simulate  a  melancholia  with  stupor.  The  age 
and  the  intellectual  defect  present  will  be  in  favor  of  the  former.  But 
senile  melancholia  is  particularly  apt  to  present  an  apparent  defect  of 
intellect. 

The  possibility  of  the  melancholia  being  a  phase  of  a  circular  in- 
sanity is  also  to  be  borne  in  mind. 

There  are  instances  of  such  a  disorder  as  typhoid  fever  being  tem- 
porarily mistaken  for  melancholia,  but  naturally  the  course  of  the 
temperature  and  the  character  of  the  stupor  or  delirium  would  soon 
correct  such  an  error. 

Prognosis. — The  facts  which  will  shape  prognosis  are  to  be  drawn 
from  what  has  been  said  previously  in  regard  to  the  course  and  termina- 
tion of  melancholia.  In  simple  forms  of  the  disorder  the  prognosis  is 
very  favorable  indeed,  and  recovery  can  be  predicted  in  from  three  to 
six  months.  In  the  agitated  type  the  outlook  is  less  favorable,  and  in 
hallucinated  and  apathetic  forms  still  less  so.  The  catatonic  variety  is 
the  least  favorable  of  all  as  regards  recovery. 

Treatment. — The  first  consideration  in  the  treatment  of  acute 
melancholia  is  isolation.  Separation  from  the  friends  and  relatives  and 
removal  from  the  environment  in  which  the  psychosis  has  developed  are 
of  the  greatest  importance.  With  familiar  faces  and  objects  about  him, 
and  with  his  kin  offering  their  help  and  sympathies,  the  keenest  realiza- 
tion of  his  condition  is  brought  home  to  the  melancholiac.  He  feels 
among  them  all  the  more  deeply  a  sense  of  his  incapacity,  of  his 
inability  to  fulfil  the  ordinary  duties  and  demands  of  his  usual  daily  life. 
Whether  the  patient  is  to  be  isolated  by  commitment  to  an  asylum 
depends  upon  several  circumstances  :  his  means  ;  the  intensity  of  his 
malady  ;  the  presence  of  suicidal  tendencies.  There  are  very  mild  cases 
in  which  moderate  travel,  a  sojourn  in  the  country  with  a  nurse,  a  few 
months  at  the  house  of  some  country  physician  or  in  a  small  private 
asylum,  will  result  in  recovery.  But  the  responsibility  for  such  a 
course  must  rest  with  the  physician  who  advises  it,  and  he  must  keep  in 
mind  the  danger  of  suicide  in  even  the  mildest  type  of  melancholia. 
Not  a  few  lives  have  been  needlessly  sacrificed  by  the  inexpertness  of 


710  MENTAL  DISEASES. 

the  consulting  physician.  Besides  extreme  watchfulness  on  the  part  of 
the  caretaker,  who  is  not  to  leave  the  patient  alone  either  night  or  clay, 
a  modified  or  a  complete  rest-cure  is  to  be  undertaken.  For  mild 
degrees  of  melancholia  rest  in  bed  from  6  P.  m.  until  noon  of  the  next 
day,  with  plenty  of  out-of-door  exercise  during  the  remainder  of  the  after- 
noon, is  most  commendable.  For  the  more  severe  types,  continual  rest 
in  bed  is  requisite.  The  food  should  naturally  be  easily  digestible 
and  assimilable,  and  the  patient  should  be  made  to  take  considerable 
quantities  of  milk  and  milk  products  (koumiss,  matzoon,  somal,  etc.), 
raw  eggs,  meat-juices,  and  stimulants,  when  these  are  indicated. 
Massage  and  general  faradization  (sufficiently  strong  to  contract  the 
muscles)  are  useful  to  take  the  place  of  exercise  in  cases  taking  the 
complete  rest-cure.  Constipation  should  be  regularly  counteracted  by 
abdominal  massage,  frequent  purgation,  glycerin  injections,  enemata, 
etc.  This  is  particularly  necessary  in  cases  suspected  of  suffering  from 
auto-intoxication.  In  these  cases,  too,  gastro-intestinal  antiseptics — such 
as  salol,  gr.  v,  or  beta-naphtol,  gr.  v — should  be  administered  thrice 
daily  two  hours  after  eating.  Ten  grains  of  glycerophosphate  of  soda 
in  a  large  glass  of  hot  water  a  half  hour  before  eating  is  also  a  useful 
remedial  agent  in  melancholia.  For  sleeplessness  the  prolonged  warm 
bath  or  the  hot  wet-pack  is  to  be  recommended ;  in  the  event  of  their 
failure  to  induce  a  few  hours'  sleep  in  each  twenty-four  hours,  sleep- 
producing  drugs  are  necessary.  Sulphonal  and  trional,  of  each  ten  grains,, 
given  together  at  bedtime  with  a  glass  of  hot  milk  or  a  cup  of  hot 
soup,  are  efficient  in  mild  cases. 

The  opium  treatment  is  a  sort  of  specific  for  melancholia,  especially 
when  there  are  agitation  and  precordial  anxiety  and  distress.  Beginning 
with  a  medium  dose  three  or  four  times  a  day,  we  gradually  increase  it  as 
required.  Laudanum — the  solid  extract — or  codein  may  be  administered 
by  mouth.  When  employed  hypodermatically,  which  is  usually  best,  the 
watery  extract  of  morphin  is  used.  It  is  preferable  to  administer 
morphin  only  in  the  most  aggravated  cases,  and  in  these  it  may  often 
be  advantageously  combined  with  hyoscin,  hyoscyamin,  or  duboisin. 
It  is  needless  to  say  that  the  opium  treatment  should  not  be  made  known 
to  the  patient,  and  it  is  carried  out  with  more  safety,  as  regards  the  forma- 
tion of  a  habit,  when  the  patient  is  in  an  institution.  As  the  patient 
improves,  the  opium  is  gradually  reduced  until  it  can  be  finally  cut  off 
altogether.  Opium  does  not  increase  constipation,  except  possibly  for  a 
few  days  when  first  employed  ;  it  seems  actually  in  many  cases  to 
diminish  it.  Sometimes,  indeed,  we  need  to  treat  diarrheas  that  arise  as 
a  result  of  the  opium  treatment. 

As  soon  as  it  becomes  possible  to  do  so,  physical  occupation  should 
be  begun  and  encouraged.  A  life  out-of-doors,  made  interesting  by 
different  kinds  of  amusement  or  labor ;  walks,  field  studies  in  natural 
history  (botany,  ornithology,  geology,  physical  geography,  etc.),  golfr 
bicycling,  agriculture,  and  gardening — all  of  these  have  their  place 
among  the  remedial  agents  at  the  disposition  of  the  discerning  and  judi- 
cious physician. 


CIRCULAR   INSANITY.  711 


CHAPTER  VIII. 
CIRCULAR  INSANITY. 

Synonyms. — Alternating  Insanity  ;    Insanity  of  double  form  ;    Insanity  of  double 

phase  ;  Cyclic  psychosis. 

Definition. — Circular  insanity  is  a  form  of  psychosis  characterized 
by  an  alternation  of  states  of  mania  and  melancholia.  There  are 
varieties  of  circular  insanity  which  will  be  discussed  later,  but  the 
maniomelancholic  alternation  is  the  distinguishing  feature  of  all  types 
of  this  cyclic  psychosis. 

Etiology. — Heredity  plays  an  especially  significant  part  in  the 
causation  of  circular  insanity  (sixty  per  cent.).  Not  only  do  we  find  in 
the  family  history  of  the  majority  of  these  cases  hereditary  equivalents 
of  different  kinds,  but  direct  inheritance  of  this  particular  variety  of 
mental  disorder  is  strikingly  frequent. 

Many  degenerates  exhibit  a  tendency  to  an  alternating  variation  of 
mood.  Sometimes  they  are  depressed  and  sometimes  cheerful.  It  is 
probable  that  this  oscillation  of  moods  in  an  individual  with  strong 
hereditary  taint  may  be  the  rudimentary  foundation  upon  which  the 
superstructure  of  a  circular  insanity  is  subsequently  laid. 

Among  special  factors  which  tend  to  develop  cases  of  acquired  cir- 
cular insanity  are  trauma  to  the  head,  alcoholism,  hysteria,  and  epilepsy. 
The  exciting  causes  are  physical  and  moral,  such  as  have  been  described 
in  the  chapter  on  General  Etiology.  Circular  insanity  is  much  more 
common  in  women  than  in  men,  the  proportion  being  about  four  to  one. 
Many  cases  develop  about  the  age  of  puberty,  and  nearly  all  before  the 
age  of  thirty  years.  The  frequency  of  this  type  of  psychosis  as  com- 
pared with  other  forms  has  not  yet  been  determined.  It  is  only  recently 
that  it  has  begun  to  be  classified  as  a  distinct  type  in  our  asylum  statis- 
tics. Thus,  the  report  of  the  Commission  in  Lunacy  of  New  York  State 
shows  but  ninety-six  cases  of  circular  insanity  in  nearly  forty  thousand 
admissions  between  October  1, 1888,  and  October  1,  1896,  but  the  type 
had  been  recognized  in  the  reports  required  from  the  asylums  for  only 
about  a  year  of  that  time.  It  is  difficult,  therefore,  to  arrive  at  any 
certain  conclusion,  but  the  best  authorities  agree  that  five  and  perhaps 
more  cases  of  alternating  insanity  will  be  found  among  every  hundred 
insane  patients. 

Symptomatology. — The  symptoms  will  vary  at  any  given  time 
according  to  the  phase  which  the  disorder  has  reached  at  the  time  of 
examination — the  phase  of  depression  or  the  phase  of  exaltation.  The 
melancholic  period  may  present  any  one  of  the  forms  of  melancholia 
described  in  another  chapter,  from  a  simple  depressed  condition,  scarcely 
distinguishable  from  the  normal  state  of  the  patient,  to  the  most  pro- 
nounced melancholic  syndrome.  In  some  cases  we  have  melancholia 
simplex,  in  others  the  hallucinatory  variety ;  in  some  the  agitation,  in 


712 


MENTAL   DISEASES. 


others  stupor  and  catatonia.  When,  in  any  given  case,  the  melancholic 
phase  recurs  again,  it  is  prone  to  wear  the  same  features  as  in  the  first 
attack.  Thus,  mild  depression  or  simple  melancholia,  melancholia 
agitata,  or  melancholia  attonita  may  reappear  again  and  again  as  the 
cycle  returns,  with  the  same  phase  and  character  over  and  over  again. 
While  this  is  true  in  the  majority  of  cases  of  circular  insanity,  it  is  not 
always  so,  for  occasionally  the  recurring  melancholia  changes  its  type  in 
the  various  sequences.  As  intimated  in  the  chapter  on  Melancholia, 
there  is  often  a  species  of  reactive  exaltation  in  the  convalescent  stage 
of  the  disease,  and  occasionally  this  reaction  becomes  so  accentuated 
as  to  develop  a  maniacal  condition,  so  that  we  have  presented  to  us  a 
picture  very  like  that  of  an  alternating  insanity. 

Like  the  melancholic  phase,  the  maniacal  period  of  circular  insanity 


Fig.  275.— A  case  of  circular  insanity,  photographed  first  in  maniacal  or  exalted  phase,  and  some  mouths 
later  in  the  melancholic  phase  (Dr.  Atwood). 


may  vary  in  character  from  a  condition  of  mild  exhilaration  and  exalta- 
tion to  the  severest  types  of  maniacal  excitement  and  incoherence.  As 
in  the  depressed  period,  there  is  the  same  tendency  of  the  maniacal 
phase  in  its  recurrences  to  present  regularly  the  identical  features  of 
former  attacks,  though  there  are  also  exceptional  instances  here  where 
subsequent  outbreaks  wear  a  different  maniacal  aspect. 

In  the  chapter  on  Mania  is  made  mention  of  the  fact  that  the  con- 
valescence from  that  psychosis  is  not  infrequently  characterized  by  a 
reactive  depression,  a  lacrymose  irritability.  In  some  instances  this 
may  attain  to  the  degree  of  a  true  melancholia,  and  thus  place  before 
us  a  cycle  similar  to  that  of  an  alternating  insanity. 

Ordinarily  we  recognize  two  degrees  of  intensity  in  circular  insanity 
— one   in   which  both  the  mania  and  melancholia  are  mild,  and  one  in 


ailiCULA  It    INS  A  MTV. 


713 


which    both    the  mania  and  melancholia   are    severe.     But  there  are 
mixed  types,  in  which  the  mania  may  be  mild  and   the   melancholia 

severe,  or  vice  versa. 

Mild  types  of  circular  insanity — instances  in  which  both  the  depressed 
and  exalted  phases  are  so  moderate  in  degree  as  not  to  permit  of  com- 
mitment to  an  asylum — are  not  infrequently  mel  with  by  the  practi- 
tioner, and  they  are  often  difficult  cases  to  handle  properly.  Thus,  1 
have  in  mind  two  brothers,  now  over  fifty  years  of  age,  who  are  both 
afflicted  with  circular  insanity,  manifested  in  a  form  very  distressing  to 
the  relatives.  A  description  of  one  will  describe  the  other,  and  not 
only  him,  but  many  other  similar  cases  : 

E.,  male,  aged  fifty-four,  single,  with  hereditary  taint,  has  for  many 
years  been  subject  to  alternating  attacks  of  depression  and  exaltation. 
I  have  seen  and  examined  him  in  both  phases.  There  is  little,  if  any, 
discernible  interval,  but  a  gradual  merging  of  one  phase  into  the  other. 


Mental  Sfote 


_/7eute 
Deliriousjfania- 


JeuteJMt 


'a/iici 


Simple 
j^xaltatio/L- 


OimftleVi 


'epnemon- 


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Atfelarickehcu 


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vdgiiatcL. 


cfai 


Feb. 


MdJfi 


:\ 


Mayc/u 


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L 


Sept. 


Get. 


Mi 


Lee 


Fig.  276.— Scheme  of  course  of  disease  in  periodical  circular  insanity. 


The  depressed  period  lasts  for  from  three  to  six  months.  In  this,  his 
expression  is  dejected  ;  he  feels  that  life  is  a  failure,  that  he  can  not  live 
long.  He  consults  various  physicians  for  different  maladies  which  he 
thinks  may  account  for  his  general  malaise.  He  can  not  concentrate 
his  mind  on  anything,  can  not  read  or  write  letters  ;  refuses  to  transact 
the  most  necessary  business  in  connection  with  his  estate.  He  talks 
little,  and  broods  over  the  mistakes  and  follies  committed  in  the  exalted 
phase  of  his  disorder.  He  is  rather  suspicious  and  distrustful  of  his 
family.  Sometimes  he  is  inclined  to  put  an  end  to  his  misery  by  suicide. 
Little  by  little  this  weight  of  depression  begins  to  lighten,  and  he  passes 
insensibly  into  a  condition  in  which  he  begins  to  feel  himself  rejuvenat- 
ing. Life  takes  on  a  little  rosier  color ;  his  malaise  vanishes,  and  a 
sense  of  well-being  begins  to  infuse  itself  through  his  body.  His  ex- 
pression changes  from  the  fixed  look  of  deep  dejection  to  one  of  cheer- 
ful variability.  In  the  place  of  quiet  brooding  we  note  an  awakening 
interest  in  things   about  him.      He  begins  to  talk  vivaciously,  to  be 


714  MENTAL  DISEASES. 

facetious  and  jolly,  to  write  letters  to  his  friends,  to  make  frequent 
social  calls,  to  take  up  the  threads  of  affairs.  He  discards  the  doctors, 
for  his  health  and  strength  were  never  better.  He  takes  up  some  of 
his  old  hobbies,  one  of  which  is  the  collection  of  antiques,  arms,  plate, 
furniture,  pictures,  and  specimens  of  ceramic  art.  He  spends  money 
freely,  rather  too  lavishly.  His  collections  are  gathered  together  in 
storage  warehouses,  clubs,  his  own  home,  and  the  houses  of  his  friends. 
He  becomes  extravagant  and  wasteful ;  enters  on  great  schemes  of 
money-making,  in  which  he  becomes  interminably  entangled  and 
meets  with  financial  losses.  His  friends  expostulate,  and  he  becomes 
irritable  and  angry.  He  leaves  them,  to  live  in  hotels.  He  buys  a 
pair  of  fast  horses  and  takes  a  drive  of  several  weeks  all  over  the 
country  for  hundreds  of  miles  around.  He  grows  boisterous  in  his  con- 
versation, neglectful  of  the  ordinary  courtesies  and  civilities  of  social 
life,  is  lavish  in  his  invitations,  becomes  a  little  excessive  in  drinking, 
is  restless  both  night  and  day,  travels  from  one  city  to  another  on  the 
most  trivial  and  eccentric  errands.  He  sleeps  little.  Endeavors  on 
the  part  of  relatives  to  check  the  anarchy  of  his  conduct  bring  from 
him  threats  of  suits  and  of  personal  violence,  and  letters  which  are 
quarrelsome,  offensive,  even  profane.  With  all  this,  there  is  no  intel- 
lectual defect.  He  never  has  actually  attempted  any  overt  act  which 
would  put  him  under  the  control  of  the  law,  or  aid  in  his  commitment 
to  an  asylum  to  save  the  dissipation  of  his  energies  and  the  waste  of 
his  property.  Any  jury  would  discharge  him,  for  his  conversation 
would  show  good  memory,  active  intelligence,  keen-witted  replies  to 
all  questions.  Step  by  step  this  stage  of  exaltation  begins  to  pass 
away.  He  sinks  nearer  to  his  normal  level,  resumes  a  more  natural 
conduct  toward  his  family  and  friends,  until  again  the  depressive  ele- 
ments reappear  in  his  mental  condition.  Each  stadium  lasts  for  from 
three  to  six  months,  so  that  the  cycle  fills  about  one  year. 

Varieties. — There  are  two  main  varieties  of  circular  insanity.  One 
is  a  true  circular  insanity  in  which  the  phases  follow  each  other  in  a 
perfect  cycle  thus :  mania,  melancholia,  mania,  melancholia,  mania, 
melancholia,  and  so  on.  The  other  type  is  one  in  which  there  is  a 
certain  periodicity  of  the  maniomelancholic  attacks  as  follows  :  mania, 
melancholia,  interval,  mania,  melancholia,  interval,  mania,  melancholia, 
interval,  etc.  Most  cases  can  be  catalogued  under  one  of  these  two 
headings,  but  there  are  deviations  which  do  not  exactly  conform  to  these 
well-defined  types,  and  some  authors  have  attempted  to  make  further, 
but  it  seems  to  me  unnecessary,  subdivisions,  upon  the  basis  of  varia- 
tions in  the  length  of  interval  and  irregularities  in  the  sequence  of  the 
phases. 

Pathological  Anatomy. — Autopsies  have  failed  to  reveal  any  im- 
portant macroscopic  or  microscopic  changes  in  the  brain  in  circular 
insanity.  Such  autopsies  as  I  have  been  able  to  find  recorded  were  made 
upon  patients  at  an  age  which  would  naturally  reveal  some  conditions 
incident  to  senile  involution,  and  these  morbid  conditions  may  or  may  not 
have  had  relation  to  the  mental  state  of  the  patient  during  life.  The  best 
that  we  can  say,  then,  is  that,  so  far  as  we  know,  there  is  no  anatomical 


CIRCULAR   INUANITr. 


71. 


basis  as  yet  discovered  for  circular  insanity.  Disordered  nutrition — 
either  insufticience  or  perversion  of  metabolism — probably  underlie-  the 
manifestations  of  this  psychosis. 

Course  of  the  Disease. — In  some  patient-  circular  insanity  lim- 
its inception  in  the  melancholic  period,  and  in  others  it  begins  with 
the  maniacal  phase.  Usually  the  initial  stadium  is  melancholia.  The 
transition  from  the  depressed  to  the  excited  phase  and  vice  versa  is 
sometimes  astonishingly  sudden.  The  period  of  transformation  may 
occupy  but  an  hour  or  even  less.  In  most  cases  the  merging  of  one 
period  into  the  other  is  very  gradual.  Another  and  extremely  rare 
mode  of  transition  is  by  successive  alternations  of  depression  and  exalta- 
tion, an  oscillating  or  rhythmic  transformation.  Still  another  method 
of  change  is  by  means  of  a  lucid  interval,  brief  or  long,  between  the 


Mental  State.  Jan..  Feb.  Mck  ApL  May  June  July  Juq.  Sept.  Oct  Nov  Dee. 

Jjcute 
Deliriousjmxia. 

JeuieAfania.                                /     \                                       /     \ 

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^/fi'tata- 

or  Atfonita^ 

Fig.  277. — Scheme  of  course  of  disease  in  continuous  circular  insanity. 


alternating  phases,  thus  :  mania,  interval,  melancholia,  interval,  mania, 
interval,  melancholia,  interval,  etc. 

There  is  extreme  variability  in  the  duration  of  the  maniomelan- 
cholic  cycles.  Sometimes  they  exhibit  great  irregularity  of  interval, 
from  a  few  days  to  a  year  or  more.  Sometimes  the  maniacal  phase 
lasts  one  day  and  the  melancholic  one  day,  so  that  the  cycle  is  com- 
pleted in  two  days.  In  other  cases,  again,  the  cycle  is  completed  in  two 
weeks,  or  a  month,  or  a  year.  Where  alternation  is  completed  in  short 
periods,  there  is  a  tendency  to  great  regularity.  Usually  the  melancholy 
phase  lasts  longer  than  the  maniacal. 

Diagnosis. — It  is  impossible  to  make  a  certain  diagnosis  of  circular 
insanity  unless  at  least  one  maniacomelancholic  or  melancholicomania- 
cal  cycle  has  been  observed.  If,  in  a  patient  appearing  to  have  an 
ordinary  melancholia  or  an  ordinary  mania,  there  should  be  episodic 
oscillations  of  depressed  and  exalted  emotions  (as  is  sometimes  the  case 
in  either  phase  of  the  cycle  of  circular  insanity),  then  we  are  justified  in 
entertaining  a  suspicion  of  alternating  insanity.    Even  when  an  apparent 


716  MENTAL  DISEASES. 

cycle  is  brought  to  our  attention  in  a  case  of  insanity,  it  is  not  well  to 
conclude  too  quickly  that  we  are  dealing  with  circular  insanity,  for  the 
reactive  phenomena  of  mania  and  melancholia  just  referred  to  may 
closely  simulate  the  more  serious  disorder.  The  greater  the  intensity  of 
the  second  phase  in  such  cases,  the  greater  the  presumption  of  circular 
insanity. 

There  is  occasionally  danger  of  confounding  a  periodic  mania  or  a 
periodic  melancholia  with  circular  insanity,  especially  if  their  reactive 
phases  are  notable.  Naturally,  if  the  reactive  phases  are  very  pronounced, 
a  diagnosis  of  circular  insanity  would  be  justifiable. 

General  paralysis  occasionally  presents  cyclical  phases  analogous  to 
those  of  alternating  insanity,  but  the  physical  symptoms,  the  mental 
enfeeblement,  and  the  preposterous  delusions  of  the  expansive  periods  of 
paralytic  dementia  will  ordinarily  insure  a  correct  diagnosis. 

Prognosis. — Circular  insanity,  though  made  up  of  two  of  the  most 
curable  of  mental  disorders,  is,  curiously  enough,  itself  among  the  most 
incurable.  A  patient  seldom  recovers.  The  disorder  runs  a  long 
course  over  years  of  time,  terminating  ultimately  in  dementia. 

Treatment. — All  cases  of  circular  insanity  are  best  treated  in  an 
asylum  in  order  to  prevent  suicide  in  the  melancholic  phase,  and  vio- 
lence, excesses,  and  riotous  extravagance  in  the  maniacal  period.  Un- 
fortunately, it  is  not  always  possible  to  protect  the  patient  by  this 
means,  since  juries  are  prone  to  allow  every  man  his  freedom,  no  mat- 
ter how  dangerous  to  himself  or  others,  so  long  as  he  does  not  behave 
as  a  raving  maniac  before  them.  Even  in  the  intervals  of  lucidity  it  is 
better  for  the  patient  to  be  under  medical  supervision  in  some  institu- 
tion, with  the  hope  that  the  disorder  may  be  arrested  and  future  cycles 
prevented  or  postponed  by  the  treatment.  This  treatment  is  based 
upon  the  principles  described  in  the  chapter  on  Treatment  and  in  the 
chapters  on  Mania  and  Melancholia. 

The  rest-cure  and  hydrotherapy  are  recommended  for  both  phases 
of  the  cycle.  Hyoscin,  hyoscyamin,  and  duboisin  (gr.  yi^-  to  gr.  ^_) 
are  useful  in  the  excited  stage,  and  the  opium  treatment  in  the  depressed 
stage. 


CHAPTER   IX. 
EPILEPTIC  INSANITY. 

Some  ten  per  cent,  of  all  epileptics  become  insane.  Hence  the 
epileptic  neurosis  in  an  individual  renders  him  about  thirty  times  more 
liable  to  insanity  than  if  he  were  normal.  The  psychoses  to  which  the 
epileptic  is  subject  vary  extremely  in  character.  It  is  my  aim  to  give 
here  a  brief  review  of  these.  I  shall  not  consider  under  this  heading 
forms  of  mental  disorder   in  which  epilepsy  or  repeated  epileptiform 


EPILEPTIC  INSANITY.  717 

convulsions  make  their  appearance  in  conjunction  with  the  psychic  dis- 
turbance as  the  result  of  a  common  cause  (general  paralysis,  chronic 
alcoholism,  epileptic  idiocy,  paralytic  idiocy,  etc.),  but  shall  Limit  myself 
to  the  class  of  insanities  induced  by  the  epilepsy.  It  is,  firsl  of  all, 
necessary  to  dwell  for  a  moment  upon  some  of  the  ordinary  features  of 
epilepsy,  apart  from  the  familiar  phenomenon  of  muscular  convulsion. 
The  epileptic  is  subject  to  peculiar  symptom.-,  which  are  looked  upon 
as  the  equivalents  of  convulsive  seizures.  Among  these  are  sudden 
brief  losses  of  consciousness.  The  consciousness  may  be  merely  clouded 
or  completely  lost.  There  may  be  no  perceptible  concomitant  symp- 
toms. On  the  other  hand,  the  defect  of  consciousness  may  be  accom- 
panied by  some  pallor  of  the  face,  a  fixity  of  the  eyes,  or  a  partial 
local  spasm  or  movement  (strabismus,  stammering  of  a  few  words, 
grimaces,  lifting  the  arm,  bowing  movement  of  the  body,  turning  of 
the  head,  etc.).  The  disorder  of  consciousness  may  be  associated  with 
an  automatic  dream-state,  similar  to  somnambulism,  in  which  compli- 
cated impulsive  movements  take  place  (automatic  continuance  of  acts 
begun  before  the  seizure,  purposeless  running,  undressing,  etc.).  Ver- 
tiginous attacks  may  be  the  equivalent  of  convulsions.  The  aura  of  an 
epileptic  attack  may  be  in  the  form  of  a  hallucination.  A  study  of 
the  psychology  of  epileptics  in  general  gives  us  a  sort  of  composite 
picture,  to  which  all  of  these  patients  conform  more  or  less  closely. 
The  mental  attitude  of  the  epileptic  is  due  to  a  variety  of  circumstances. 
In  the  first  place,  he  has  a  consciousness  of  the  dreadful  nature  of  his 
malady.  He  is  in  a  state  of  expectant  attention  as  regards  the  sudden 
blackness  and  prostration  which  are  to  strike  him  unawares  at  any 
time,  in  any  place,  like  the  lightning  from  a  clear  sky.  He  can  never 
share  the  social  pleasures  of  his  fellows.  The  "schools  are  not  open  to 
such  as  he.  When  he  becomes  old  enough  to  work,  he  finds  that  no  one 
wishes  to  employ  him.  Every  avenue  of  education,  every  trade  and 
calling,  every  road  to  mental  progress,  is  barred.  He  is  a  social  out- 
cast, an  object  of  commiseration,  a  burden  to  his  friends,  perhaps  a 
family  blemish  to  be  kept  concealed.  The  doctor  is  called  in,  and, 
taking,  as  a  rule,  a  hopeless  view  of  the  case,  abandons  him  to  the 
mercy  of  the  bromids,  which  further  his  mental,  physical,  and  moral 
degradation.  In  this  way  the  epileptic  character  is  evolved.  It  con- 
sists of  a  mixture  of  melancholy,  hypochondriasis,  emotional  irritabil- 
ity, moroseness,  distrust,  misanthropy,  mental  apathy,  and  dullness, 
often  combined  with  morbid  religious  tendencies  and  modified  by  patho- 
logical psychic  conditions  incident  to  the  ravages  of  the  disease  itself. 
These  pathological  mental  states  vary  from  the  peculiar  psychic 
equivalents  just  described  to  the  actual  psychoses  of  divers  forms 
now  to  be  detailed.  Epileptic  insanity  is  chiefly  a  progressive  psychic 
deterioration  terminating  in  dementia.  But  the  progressive  degenera- 
tion is  frequently  marked  by  episodic  outbreaks  of  psychoses  under 
various  forms.  Among  these  are  transitory  hallucinatory  and  stupor- 
ous disorders  and  chronic  epileptic  psychoses  (under  any  form,  such  as 
mania,  melancholia,  circular  insanity). 

Psychic  Degeneration  of  Epileptics. — As  is  well  known,  severe 


718  MENTAL  DISEASES. 

epileptic  attacks  are  ordinarily  followed  by  a  somnolent  and  stuporous 
condition  lasting  from  an  hour  or  two  to  several  days.  The  frequent 
repetition  of  such  attacks  tends  to  render  complete  recovery  from  such 
mental  torpor  more  and  more  difficult.  As  a  consequence,  we  observe  a 
gradual  weakening  of  the  intellectual  processes.  The  flow  of  ideas  is 
retarded  and  the  expression  of  such  ideas  along  motor  lines  becomes 
sluggish ;  the  speech  especially  has  a  characteristic  slowness ;  atten- 
tion is  diminished  and  memory  impaired  ;  the  concepts  and  judgments 
are  built  up  with  ever-slackening  activity.  In  this  way  the  epileptic 
may  sink  gradually  into  a  deepening  simple  dementia.  In  some  cases 
the  concepts  attended  with  ethical  feelings  vanish  first,  and  to  so 
striking  an  extent  that  acts  of  violence,  cruelty,  brutality,  and  crime  are 
committed  without  a  single  inhibitory  effort  or  a  shadow  of  remorse. 
These  acts  often  have  an  impulsive  character. 

An  excessive  irritability  of  temper  is  a  phase  of  epileptic  psychic  de- 
generation. The  most  trivial  incidents  may  give  rise  to  outbursts  of 
anger  and  even  of  overwhelming  fury. 

The  natural  hypochondriacal  depression  of  many  epileptics  is  fre- 
quently much  exaggerated,  giving  rise  to  a  sort  of  melancholia  colored 
by  mental  enfeeblement,  and  by  suspicion,  distrust,  misanthropy,  and 
moroseness. 

Occasionally,  in  the  midst  of  this  progressive  deterioration  of  mind, 
imperative  ideas  and  acts  manifest  themselves,  and  delirious  states 
appear  with  dreadful  hallucinations  and  delusions  of  persecution 
(paranoia-like  outbreaks). 

These  are  the  marks  which  distinguish  the  psychic  side  of  the 
gradually  developed  dementia  of  epileptics.  The  mental  enfeeblement 
is  accompanied,  as  in  terminal  dementias  generally,  by  increase  in 
bodily  weight,  hypertrophy  of  the  subcutaneous  fatty  tissue,  and  the 
gradual  effacement  of  the  lines  of  expression  in  the  features.  We  thus 
reach  ultimately  the  condition  of 

Epileptic  Dementia. — As  intimated,  the  rate  of  progress  of 
epileptic  dementia  is  in  direct  proportion  to  the  number  and  severity  of 
seizures.  There  are  cases  which  go  on  to  the  terminal  stage  without 
some  of  the  peculiar  manifestations  of  progressive  epileptic  degeneration 
just  described,  and  others,  again,  in  which  these  features  are  prominent. 
The  dementia  may  be  absolute,  so  that  not  the  simplest  concrete  memory- 
picture  remains  in  the  vacant  mind ;  the  patient  needs  care  in  his  per- 
son and  dress,  and  often  has  to  be  guided  and  assisted  in  taking  nourish- 
ment. His  sensibilities  become  so  diminished  that  he  is  indifferent  to 
stimulation  of  any  sense,  and  has  no  perception  of  the  needs  of  the  body 
as  regards  the  bowels  or  bladder.  He  must  be  cared  for  like  an  infant. 
A  persistent  sexual  instinct  often  impels  him  to  constant  masturbation. 

During  progress  into  dementia,  we  note  the  intercurrent  hallucinatory 
states  already  mentioned,  and  the  accesses  of  anger,  with  assaults  and 
impulsive  actions  of  various  kinds.  The  motor  memories  suffer  in  the 
end  to  such  degree  that  all  complicated  movements  are  forgotten.  This 
is  particularly  noteworthy  in  the  use  of  words,  which  are  separated  by 
considerable  pauses.    Often  even  the  syllables  are  thus  divided.    Finally, 


EPILEPTIC  INSANITY.  71!) 

the  patient  loses  the  power  of  speech  altogether  (aside  from  the  actual 
aphasic  attacks,  whieh  are  not  infrequently  observed  in  connection  with 
severe  epileptic  seizures). 

The  course  of  epileptic  dementia  is  rarely  rapid  ;  it  usually  extend- 
over  a  period  of  years.  The  cause  of  death  is  usually  accident,  status 
epilepticus,  pneumonia,  intestinal  catarrh,  inflammation  of  the  bladder, 
or  some  other  intercurrent  affection.  Epileptic  dements  exhibit  a 
diminished  resistance  to  diseases  in  general,  and  never  attain  great  age. 

Acute  Transitory  Epileptic  Insanity. — The  acute  insanity  of 
epileptics  develops  suddenly  before  a  convulsive  seizure,  after  the  attack, 
or  it  may  occur  in  the  interval  between  the  epileptic  convulsions,  com- 
monly in  the  place  of  a  convulsion,  as  a  so-called  psychic  equivalent. 
As  a  rule,  both  onset  and  termination  are  sudden.  The  duration  of  the 
insanity  is  ordinarily  from  a  few  hours  to  a  few  day.-,  though  the  attacks 
are  sometimes  shorter  and  sometimes  longer.  The  symptoms  are  pecu- 
liar and  various.  The  chief  characteristic  is  the  clouding  of  conscious- 
ness. The  patient's  state  may  be  one  of  complete  unconsciousness, 
though  usually  consciousness  is  not  entirely  lost.  It  is  rather  a  condi- 
tion of  subconsciousness  or  of  subliminal  consciousness,  with  stupor. 
Upon  this  screen  of  clouded  consciousness  there  is  a  play  of  multiform 
and  bizarre  psycopathic  outlines — many-hued,  terrible,  or  ecstatic  hallu- 
cinations ;  delirium,  mutism,  incoherence,  verbigeration,  anxious  states, 
delusions  (often  of  a  persecutory  nature),  or  irresistible  impulsions  to 
assault,  destructiveness,  homicide,  and  suicide.  Sometimes  the  funda- 
mental tone  of  the  outbreak  is  melancholic,  more  often  maniacal,  but 
the  most  appropriate  designation  of  these  acute  epileptic  psychoses  is, 
perhaps,  acute  hallucinatory  paranoia.  There  is  no  essential  difference 
between  them,  whether  the  attack  be  preparoxysmal  or  postparoxysmal, 
or  the  equivalent  of  the  paroxysm. 

The  stupor  of  epileptic  insanity  is  distinguished  from  that  of  other 
psychoses  by  marked  loss  of  consciousness,  enfeebled  attention,  anal- 
gesia, sudden  violence,  and  confusion. 

We  sometimes  observe  in  connection  with  subconsciousness  primary 
anxious  states,  resembling  precordial  dread,  with  extremely  painful 
sensations  of  oppression  and  suffocation  in  the  breast ;  and  much  more 
rarely  primordial  exaltation,  with  acceleration  of  the  stream  of  ideas. 

Hallucinations  are  mostly  limited  to  the  visual,  auditory,  and  olfac- 
tory senses,  chiefly  to  the  first-named.  The  patient  sees  wild  beasts, 
specters,  flames,  the  fires  of  hell,  wheels,  gigantic  threatening  objects, 
falling  walls,  overwhelming  wTaves  of  water ;  or,  on  the  other  hand,  the 
golden  gates  of  heaven,  the  jasper  throne,  God,  and  the  choir  of  angels. 
He  hears  menacing  voices,  clamor  and  uproar,  the  thunder  of  cannon, 
or  the  singing  of  the  hosts  of  heaven,  the  voice  of  God,  etc.  Disagree- 
able and  noxious  or  pleasant  odors  may  be  perceived.  A  peculiarity 
of  these  hallucinations  is  a  certain  monotony  of  character,  a  general 
sameness,  in  great  part  due  to  the  rather  child-like  constitution  of  the 
mind  of  epileptics.  Their  education  and  mental  evolution  are  so  often, 
from  the  nature  of  their  malady,  hampered  and  retarded,  that  they  pass 
through  life  with  the  fancy  and  understanding  of  a  child. 


720  MENTAL  DISEASES. 

Incoherence  of  speech  and  lack  of  orientation  as  to  surroundings 
are  more  marked  in  epileptic  insanity  than  in  any  other  psychosis. 

The  motor  symptoms  vary  extremely.  Sometimes  we  note  motor 
inhibition  attaining  to  complete  immobility  and  mutism,  lasting  for 
hours,  days,  or  weeks  at  a  time.  Such  quiescence  is  often  interrupted 
by  sudden  explosive  acts  of  violence.  Again,  in  other  cases,  we  ob- 
serve agitation,  restless  wandering  about,  purposeless  and  impetuous 
running  hither  and  thither,  assaults,  destructiveness,  and,  rarely,  com- 
plicated acts,  like  theft  and  other  petty  crimes.  A  condition  of  relig- 
ious ecstasy  is  not  uncommon.  The  patient  may  feel  himself  wafted  to 
heaven,  where  he  converses  with  God,  Christ,  and  the  disciples. 

In  some  rare  instances  epileptics  are  subject  to  dream-like  states  of 
subconsciousness,  similar  to  somnambulism,  in  which  complicated  acts 
are  carried  out.  Like  the  somnambulist,  such  patients  may  seem  to  be 
conscious,  may  comport  themselves  in  speech  and  conduct  in  a  perfectly 
natural  manner,  and  in  this  condition,  which  may  last  for  hours,  days, 
or  even  weeks,  commit  offenses  against  the  law,  wander  off  as  tramps, 
or  do  some  extraordinary  thing  in  following  the  imperative,  childish, 
silly,  or  fantastic  ideas  which  control  their  dream-state. 

The  disorders  of  memory  incident  to  transitory  epileptic  insanity 
are  both  interesting  and  important.  There  may  be,  upon  recovery,  ab- 
solute amnesia  as  regards  everything  that  has  taken  place.  There  may 
be  remembrance  of  much  that  has  occurred  immediately  after  the  in- 
sanity has  passed,  with  subsequent  amnesia.  There  may  be  complete 
amnesia  at  first,  with  glimpses  of  remembrance  afterward.  There  is 
rarely  any  persistent  recollection  of  the  events  of  the  psycopathic 
state. 

As  has  been  stated,  the  rule  is  for  these  transitory  epileptic  insanities 
to  exhibit  a  sudden  onset  and  a  sudden  termination.  The  longer  the 
duration,  the  less  abrupt  the  cessation.  The  majority  of  these  patients 
recover,  but  recurrence  is,  of  course,  frequent.  Termination  in  a  chronic 
condition  is  rare.  Occasionally,  death  takes  place  from  exhaustion,  in- 
tercurrent maladies,  or  from  a  convulsive  seizure  or  series  of  attacks 
during  the  psychosis.  Recurrences  tend  to  hasten  a  psychic  degenera- 
tion ending  in  dementia. 

The  epileptic  nature  of  such  insanity  as  is  here  described,  where  the 
history  is  not  known,  is  determined  by  the  following  characteristics  :  (1) 
Sudden  onset  and  abrupt  termination  ;  (2)  the  terrifying  or  ecstatic 
nature  of  the  hallucinations  and  delusions  ;  (3)  disturbance  of  conscious- 
ness and  stuporous  condition  ;  (4)  impulsive  acts  ;  (5)  dream-states  ;  (6) 
amnesia. 

Chronic  Epileptic  Insanity. — Aside  from  epileptic  dementia,  the 
acute  epileptic  psychosis  just  described  may  take  a  chronic  course,  or 
assume  a  periodic  form,  with  little  improvement  in  the  intervals  between 
the  exacerbations.  There  are  cases  which  closely  resemble  chronic 
mania  in  their  long  course,  and  others  in  which  melancholia  is  the  pre- 
dominating feature.  The  epileptic  attacks  to  which  these  patients  are 
subject  are  naturally  the  distinguishing  feature,  and  a  special  color  is 
given  such  cases  by  the  epileptic  psychic  degeneration.     Occasionally  a 


EPILEPTIC  INSANITY.  721 

true  circular    insanity  is  presented,  with  its  alternating  maniacal  and 
melancholic  phases. 

Treatment. — Most  cases  of  pronounced  epileptic  insanity  require 
commitment  to  an  asylum.  Their  proclivity  to  sudden  accesses  of  rage 
and  fury  and  to  impulsive  acts  of  violence  necessitates  this  course. 
Where  there  is  simply  a  moderate  amount  of  psychic  degeneration  this 
course  is  not  necessary. 

The  treatment  should  be,  in  the  first  instance,  prophylactic  ;  but,  after 
the  development  of  the  psychosis,  it  consists  of  a  combination  of  the 
treatment  of  ordinary  epilepsy  with  that  of  the  particular  type  of  insanity 
presented. 

Preventive  therapy  is  concerned  with  the  counteraction  of  the  many 
elements  which  favor  mental  deterioration,  with  the  mitigation  of  the 
epileptic's  early  sufferings,  with  the  reconstruction  of  his  environment. 
It  may  be  called  the  moral  and  manual  method.  The  moral  part  of  it 
is  the  opportunity  for  education,  regular  occupation,  and  recreation. 
The  manual  and  hygienic  part  of  it,  the  acepjisition  of  out-of-door  trades 
or  callings — muscular  exercise,  which  in  itself  serves  to  reduce  the 
number  and  intensity  of  convulsive  seizures.  I  may  be  pardoned  for 
dwelling  somewhat  longer  on  this  subject  of  preventive  therapy,  and  for 
allowing  my  pen  to  go  over  the  same  lines  which  it  has  traveled  so 
often  in  past  years,  because  I  am  convinced  that  this  moral  treatment 
marks  the  greatest  stride  in  advance  made  for  centuries  in  the  thera- 
peutics of  epilepsy.  For  ages  drugs  have  been  exploited  as  helpful  or 
curative  ;  but,  after  all,  little  has  been  accomplished  from  the  standpoint 
of  materia  medica.  Only  of  late  years  has  the  moral  treatment  become 
prominent.  As  a  rule,  the  epileptic  patient  was  dismissed  by  his  physician 
with  a  prescription  of  uncertain  value  and  possibly  a  few  general  direc- 
tions as  to  diet.  It  was  not  known  to  the  practitioner — or,  at  least,  he 
did  not  concern  himself  about  the  matter — that  the  epileptic  could  gain 
admission  to  no  hospital  of  any  kind  ;  that  he  had  no  associates,  occu- 
pation, or  recreation  ;  that,  debarred  from  the  schools,  he  grew  up  un- 
educated, and  with  a  tendency  toward  retrogression  rather  than  progress  ; 
and  that,  without  teaching,  reared  in  idleness,  suffering  from  a  dreadful 
malady,  neglected  in  body  and  mind,  he  could  find  shelter  at  last  only 
in  the  almshouses  and  insane  asylums,  these  being  the  only  institutions 
open  to  him.  Yet,  in  by  far  the  majority  of  cases  of  epilepsy,  the 
attacks  rob  them  for  but  brief  intervals  of  the  capacities  for  study, 
work,  recreation,  and  social  pastimes,  which  they  possess  in  common 
with  their  more  fortunate  fellow-men.  Hence  the  adoption  of  a  scheme 
of  colonization  of  epileptic  dependents  on  the  model  of  the  great  German 
colony  at  Bielefeld,  of  which  the  Craig  Colony,  in  the  State  of  New 
York,  is  an  example.  The  Craig  Colony  consists  of  a  tract  of  nearly 
nineteen  hundred  acres  of  land  in  the  most  fertile,  productive,  and  pictur- 
esque valley  of  the  State  (the  Genesee  Valley).  Upon  this  are  already 
some  fifty  to  sixty  buildings,  with  accommodations  at  present  for  but 
300  patients.  Over  fifteen  hundred  epileptics  are  now  on  the  list  of 
patients  awaiting  admission.  Here  they  are  to  be  given  an  education 
in  the  various  branches  of  learning  taught  in  the  public  schools,  to  be 
46 


722  MENTAL   DISEASES. 

instructed  in  every  kind  of  industry,  to  be  treated  each  and  every  one 
for  epilepsy,  and  to  be  offered  a  home  in  a  sort  of  village  life,  where 
they  will  no  longer  have  the  feeling  of  social  ostracism,  or  be  debarred 
from  the  privileges  of  intellectual  and  moral  development  enjoyed  by 
the  rest  of  mankind. 

The  out-of-door  life  in  a  farming  community  has  already  had 
wonderful  results,  which  may  be  learned  from  the  annual  reports  of 
the  colony.  It  will  suffice  to  say  here  that  the  average  reduction  in 
frequency  of  attacks  among  all  the  patients  has  been  fully  fifty  per 
cent.,  and  that  the  mental  and  moral  regeneration  of  the  beneficiaries 
has  been  truly  remarkable.  What  the  effect  of  such  change  of  environ- 
ment must  be  as  a  prophylactic  against  psychic  degeneration  and  insanity 
can  not  be  estimated.  We  may  now  briefly  touch  upon  the  medicinal 
and  surgical  treatment  of  epilepsy.  The  old  drugs — borax,  nitrate  of 
silver,  belladonna,  and  the  bromids — have  their  uses.  One  is  valuable 
in  one  case  and  not  in  the  other ;  and  each  patient,  where  the  disease  is 
idiopathic,  and  no  etiological  indication  exists  for  the  preferment  of  an 
especial  agent,  must  be  experimented  upon  with  one  drug  after  another 
for  two  or  three  months  at  a  time,  until  a  satisfactory  remedy  is  discov- 
ered. Upon  the  whole,  the  bromids  are  most  effective  as  a  general 
antispasmodic  for  all  cases.  While  the  bromids  are,  perhaps,  the  most 
useful  remedy  we  can  employ  as  an  antispasmodic  in  many  cases  of 
epilepsy,  their  exhibition  in  every  case  is  not  advisable.  With  a  con- 
siderable number  of  patients  the  bromids  are  entirely  ineffectual ;  with 
no  small  number,  too,  very  serious  symptoms,  such  as  acute  bromism, 
increase  of  seizures,  and  even  insanity,  supervene  upon  their  use.  In 
many  of  the  cases  where  actual  good  is  done  by  the  bromids  in  reduc- 
ing the  frequency  and  severity  of  the  attacks,  the  concomitant  symptoms 
are  such  that  it  becomes  questionable  whether  the  remedy  be  not,  after 
all,  worse  than  the  disease.  The  writer  makes  it  a  practice,  therefore,  to 
exhibit  the  bromids  with  caution,  and  never  to  employ  them  until  the 
series  of  less  harmful,  but  often  quite  as  efficacious,  remedies  for  epilepsy 
have  been  tried  in  vain. 

There  are  some  new  drugs  and  remedial  methods  that  have  come 
into  vogue  of  late  which  are  worthy  of  attention.  In  the  first  place, 
there  is  simulo,  a  South  American  plant  of  the  hyssop  family,  the  tinc- 
ture of  which  is  given  in  doses  of  one  to  two  or  three  drams  three  times 
daily.  After  an  experience  in  many  cases  for  several  years,  I  would 
say  of  simulo  that  it  deserves  trial  in  most  cases ;  that  it  is  perfectly 
harmless,  which  can  not  be  said  of  the  bromids,  borax,  belladonna,  and 
some  other  drugs  ;  that  in  a  few  cases  it  has  been  extremely  beneficial 
in  my  hands,  and  that  in  most  cases  it  has  no  effect  at  all.  Simulo 
combined  with  small  doses  of  bromid  acts  very  well.  The  so-called 
opium-bromid  treatment  of  Flechsig  is  of  value  for  many  patients, 
especially  in  old  and  obstinate  cases  where  all  other  agents  have  proved 
ineffectual.  This  treatment  consists  of  the  administration  of  opium  for 
some  six  weeks,  beginning  with  one-half  to  one  grain  three  times  daily, 
and  increasing  gradually  until  ten  to  fifteen  grains  a  day  are  taken,  when 
the  use  of  opium  is  suddenly  stopped,  and  bromids  in  large  and  grad- 


EPILEPTIC  INSANITY.  IT.', 

ually  reduced  doses  are  given  (thirty  grains  four  times  daily,  to  begin 
with).  I  had  used  in  certain  cases  of  epilepsy  for  sonic  years  codein 
with  considerable  success,  but  this  combination  of  the  opiate  with  bro- 
mids  is  still  more  satisfactory. 

Adonis  vernalis  conjoined  with  the  bromids,  as  recently  suggested 
by  Bechterew,  is  an  efficient  method  of  treatment,  from  which,  in  several 
instances,  I  have  had  gratifying  results.  Digitalis,  which  has  proper- 
ties similar  to  Adonis  vernalis,  was  formerly  frequently  given  in 
epilepsy,  but  the  new  combination  seems  to  be  much  more  efficacious. 

There  are  a  few  cases  of  epilepsy  in  which  careful  investigation  indi- 
cates self-intoxication  as  a  factor.  In  these  an  excess  of  ethereal  sul- 
phates (indican)  in  the  urine,  together  with  periodical  or  constant  attacks 
of  gaseous  diarrhea,  are  almost  positive  manifestations  of  putrefactive 
or  fermentative  changes  taking  place  in  the  alimentary  tract.  It  is  re- 
markable how  much  benefit  may  be  obtained  in  such  patients  by  the 
regulation  of  the  diet  (milk  and  its  modifications,  koumiss,  matzoon, 
somal,  rare  or  raw  beef,  eggs,  green  vegetables,  and  special  breadstuff's, 
like  Zweiback,  Huntley  &  Palmer's  breakfast  biscuits,  and  Yoebt's 
biscotte  de  legumine),  by  the  frequent  drinking  of  hot  water  and  the 
occasional  flushing  out  of  the  large  intestine  by  hot  water,  and  by  the 
use  of  certain  intestinal  antiseptics,  given  two  hours  after  eating,  with 
plenty  of  water  (beta-naphtol  or  salol,  gr.  v). 

The  remarkable  effect  of  the  thyroid  extract  upon  general  nutrition 
would  naturally  suggest  the  advisability  of  its  administration  for  experi- 
mental purposes  in  some  of  the  nervous  diseases  wrhich  we  are  accus- 
tomed to  look  upon  as  due  to  nutritional  disturbances  in  the  nervous 
system.  With  this  idea  in  view,  I  have  employed  it  in  a  good  many 
cases  of  epilepsy,  in  a  number  with  very  good  effect.  Especially  note- 
worthy was  mental  improvement  in  several  cases  of  epilepsy  with 
apparently  considerable  dementia.     It  is  worthy  of  more  extended  trial. 

Aside  from  the  remedies  for  the  epilepsy  just  described,  we  need 
occasionally  to  employ  certain  other  drugs  for  particular  conditions, 
such  as  status  epilepticus,  maniacal  outbreaks,  pronounced  melan- 
cholic states  of  terror,  etc.  In  status  epilepticus  rectal  injections  of 
chloral,  gr.  xx,  with  an  ounce  of  starch-water,  repeated  at  intervals  of 
two  or  three  hours  if  needed,  give  the  most  satisfaction.  In  great  ideo- 
motor  excitement  we  should  use  hyoscin,  hyoscyamin,  or  duboisin 
hypodermatically,  in  doses  of  yi-g-  to  -^  of  a  grain.  In  anxious  melan- 
cholic conditions  morphin  hypodermatically  is,  perhaps,  the  best  allevi- 
ating agent  to  exhibit. 

The  question  of  trephining  must  naturally  come  up  in  certain  cases 
of  epileptic  psychoses  where  trauma  to  the  head  is  evidently  the  cause 
of  the  epilepsy  and  psychic  degeneration.  The  following  points  are  to 
be  taken  into  consideration  as  a  guide  in  this  matter : 

1.  In  the  very  small  number  of  cases  having  injury  to  the  head  as 
a  cause  the  epileptic  habit  is  so  strong,  and  the  changes  in  the  brain 
are  usually  so  old  and  deep-seated,  that  an  operation,  as  a  rule,  does 
not  cure,  and  seldom  permanently  diminishes  the  frequency  of  the 
attacks. 


724  MENTAL  DISEASES. 

2.  Of  miscellaneous  traumatic  cases,  where  a  surgical  procedure 
seems  justifiable  and  is  undertaken,  a  cure  of  the  epilepsy  may  be 
reasonably  expected  in,  perhaps,  four  out  of  every  hundred  cases 
operated  upon. 

3.  The  removal  of  a  cicatrix  from  the  cortex,  supposed  to  be  the 
epileptogenic  nidus,  will  naturally  be  followed  by  the  formation  of  a 
new  cicatrix  in  the  surgical  wound — the  creation,  therefore,  of  a  new 
epileptogenic  center. 

4.  The  more  recent  the  injury,  the  greater  will  be  the  promise  of 
lasting  benefit. 

5.  In  cases  of  traumatic  epilepsy  with  marked  epileptic  psychoses 
(recurrent  attacks  of  rage,  fury,  violence,  destructiveness,  etc.)  trephin- 
ing would  be  justifiable  as  a  possible  means  of  diminishing  the  severity, 
danger,  and  frequency  of  the  maniacal  attacks,  even  though  the  epilepsy 
itself  or  the  psychic  degeneration  might  not  be  improved. 


CHAPTER    X. 

DEMENTIA. 

Secondary;  Senile;  Primary* 

Definition. — "  Dementia  "  is  a  term  employed  to  designate  simply  a 
general  enfeeblement  of  all  the  mental  faculties.  It  is  often  used  im- 
properly by  the  laity  as  synonymous  with  insanity.  But  in  medicine  it 
signifies  only  a  general  weakening  of  a  mind  once  normal.  Hence  it  is 
not  applied  to  congenital  mental  weakness.  The  term  "  idiocy,"  with  its 
various  degrees,  includes  all  of  these  congenital  psychic  defects.  There 
are  innumerable  gradations  comprised  in  dementia,  from  the  merest 
dullness  to  profound  deficiency  or  complete  loss  of  all  the  intellectual 
faculties.  Such  enfeeblement  of  the  mind  may  be  the  result  of  serious 
cerebral  diseases  or  disorders,  such  as  epilepsy,  alcoholism,  syphilis,  etc., 
when  the  dementia  is  qualified  as  epileptic,  alcoholic,  syphilitic  dementia, 
etc.  It  is  often  a  sequel  to  acute  insanities,  like  mania  and  melancholia, 
and  to  chronic  psychoses,  like  circular  insanity  and  paranoia,  and  hence 
the  distinctive  term  secondary  dementia  applied  to  such  examples.  It 
takes  the  chief  part  in  the  syndrome  of  paresis,  so  that  that  disorder  is 
often  entitled  "  paralytic  dementia."  Progressive  mental  enfeeblement 
not  infrequently  accompanies  senile  involution  and  organic  changes  in 
the  brain  incident  to  that  epoch  of  life  ;  hence  the  well-known  disorder 
called  senile  dementia.  Finally,  there  is  a  form  of  mental  disease  charac- 
terized in  the  main  from  the  very  beginning  by  extraordinary  psychic 
enfeeblement,  and  this  malady  is  classified  as  an  acute  or  primary 
dementia. 


DEMENTIA.  725 

Under  the  heading  of  dementia  we  shall  now  consider  separately  the 
more  important  forms  of  dementia  just  described — viz.,  secondary 
dementia,  senile  dementia,  and  primary  dementia. 


SECONDARY  DEMENTIA. 

Secondary  dements  make  up  by  far  the  greater  number  of  the 
patients  accumulated  in  our  large  asylums.  Every  year  the  number  is 
augmented  by  the  increment  of  new  cases  which  enter  upon  this  terminal 
and  incurable  condition.  It  has  been  estimated  that  some  two-thirds  of 
the  patients  in  asylums  belong  to  this  category. 

Symptomatology. — The  cardinal  symptoms  are  defect  of  memory, 
deficient  ideation,  and  feebleness  of  judgment.  There  is  no  longer  any 
logical  coordination  in  the  flow  of  thought.  The  speech  is  incoherent 
when  there  are  any  ideas  at  all  to  seek  expression.  Some  patients 
chatter  a  great  deal  with  no  coherence  or  meaning,  the  only  connection 
of  one  word  or  phrase  with  another  being  similarity  of  sound.  Other 
patients  are  absolutely  silent.  Hallucinations  are  often  present,  more 
particularly  at  the  period  of  transition  from  the  antecedent  psychosis  to 
the  terminal  dementia.  Delusions  may  also  exist,  but  they  are  vestiges 
of  the  delusions  of  the  primary  insanity  carried  over  into  the  secondary 
condition.  The  feebleness  of  mind  is  shown  especially  in  the  state  of 
the  emotions,  which  have  a  child-like  simplicity  of  expression.  These 
patients  laugh  boisterously  over  nothing,  weep  about  trifles,  and  are 
easily  enraged  without  sufficient  motive.  Naturally,  all  of  the  higher 
concepts  are  lost,  especially  those  of  esthetic  and  ethical  character. 
The  habits  become  depraved  and  loathsome  in  extreme  cases.  Mastur- 
bation, destructiveness  of  clothing,  besmearing  of  the  person  with  and 
eating  of  filth  are  frequent  manifestations  in  the  lowest  degrees  of 
dementia.  The  patients  become  robust  and  fat.  They  lose  all  expression, 
save  some  single,  automatic,  fatuous  smile,  angry  frown,  furtive  look,  or 
aspect  of  misery,  which  may  linger  as  a  legacy  from  the  previous  psy- 
chosis. They  swallow  anything  they  can  get  hold  of;  they  collect 
pebbles,  pieces  of  paper,  string,  glass, — in  fact,  all  sorts  of  rubbish, — 
which  they  either  pocket  or  use  for  personal  ornament.  Many  show  a 
proclivity  to  automatic  movements,  analogous  to  those  observed  in 
idiocy,  such  as  anteroposterior  or  lateral  oscillations  of  the  body.  Occa- 
sionally these  movements  are  more  complicated,  taking  the  form  of 
grimaces  ;  gesticulations  with  the  fingers,  hands,  and  arms  ;  running  to 
and  fro,  running  in  a  circle,  whirling  round  on  the  heel,  etc.  A  con- 
siderable loss  of  sensibility  to  pain  is  generally  noticeable  in  secondary 
dements.      Hematoma  auris  is  common  among  them. 

It  is  customary  to  classify  secondary  dementia  into  two  groups,  be- 
speaking contrasting  syndromes — viz.,  apathetic  and  agitated  dementia. 

Patients  with  apathetic  dementia  are  expressionless,  never  speak, 
crouch  or  lie  about  the  floor  or  in  corners  in  the  most  negligent  attitudes, 
and  cover  their  heads  with  their  clothing. 

Patients  with  agitated  dementia  are  the  restless  ones  just  alluded  to, 


726  MENTAL   DISEASES. 

and  such  cases  as  show  a  tendency  to  accesses  of  excitement.  These 
outbreaks  are  doubtless  aroused  by  processes  going  on  within  the  organ- 
ism, since  they  occur  without  any  external  exciting  cause. 

Secondary  dementia  may  be  regarded  as  a  presentment  of  the  mind 
in  ruins.  The  storm  has  swept  by  with  its  havoc  and  devastation. 
After  its  fury  has  been  spent,  a  certain  amount  of  placidity  remains. 
In  the  midst  of  this  calm  we  note  the  wreck  that  has  been  wrought. 
Some  of  the  old  architectural  details  stand  out,  so  that  we  may  still  rec- 
ognize what  manner  of  mind  it  was.  There  are  residua,  too,  of  the 
destructive  agent  that  was  at  work,  traces  that  indicate  the  character 
of  the  brain-storm  when  it  was  at  its  height. 

The  foregoing  are  the  main  outlines  of  secondary  dementia,  but,  as 
intimated  before,  there  are  innumerable  gradations  of  mental  enfeeblement 
in  these  cases.  A  large  part  of  the  work  done  in  and  about  asylums  is 
performed  by  secondary  dements  in  whom  the  intellectual  decay  is  not 
extreme. 

Course  and  Prognosis. — The  course  of  secondary  dementia  is 
chronic.  Usually,  there  is  no  progressive  increase  of  mental  enfeeble- 
ment, rather  a  pause  after  a  time,  when  the  mind  reaches  a  certain 
plane  of  deterioration.  Here  the  process  becomes  stationary.  The 
patient  leads  his  mindless,  vegetative  existence  for  years  and  years, 
sometimes  to  a  good  old  age,  because  in  the  asylum  he  lives  a  life  of 
perfect  regularity  as  to  food,  sleep,  and  exercise,  and  is  snugly  pro- 
tected from  the  vicissitudes  of  weather  and  of  the  daily  struggle  in  the 
outer  world. 

These  patients  never  recover.  Actual  tissue-alterations  were  made 
by  the  psychosis  which  swept  through  their  brains. 

Pathological  Anatomy. — Thickening  of  the  vascular  walls,  dis- 
tention of  the  perivascular  spaces,  destruction  of  ganglion-cells  and 
cortical  association  fibers,  and  some  narrowing  of  the  cortex — these  are 
the  main  postmortem  findings. 


SENILE  DEMENTIA. 

This  is  a  progressive  mental  enfeeblement  at  the  period  of  senile 
involution,  dependent  upon  organic  changes  in  the  brain  :  therefore,  a 
chronic  organic  psychosis. 

Etiology. — Heredity  has  been  noted  in  some  fifty  per  cent,  of  the 
cases.  Males  and  females  suffer  about  equally.  The  disorder  rarely 
appears  before  the  sixtieth  year.  Mental  stress  and  physical  illness, 
together  with  the  senile  involution,  are  the  chief  etiological  factors.  In 
most  of  the  cases  arteriosclerosis  takes  part  in  the  causation  of  the 
disease,  inducing,  as  it  does,  general  malnutrition  of  the  brain,  as  well 
as  frequent  local  degenerations  of  small  or  large  extent. 

Symptomatology. — The  earliest  symptom  is  failure  of  memory. 
The  most  recent  memories  disappear  first  in  a  sort  of  chronological 
order.  After  a  time  the  patient  fails  to  recognize  any  of  his  surround- 
ings or  any  of  the  people  about  him.     He  converses  with  those  near 


DEMENTIA  727 

him,  and  miscalls  them,  as  if  they  were  old  friend-  of  long  years  ago. 
lie  lives  over  old  events  as  if  they  were  now  enacted.  Later  on  even 
these  old  memories  vanish  also.  With  failing  memory,  the  judgment- 
associations  perish.  The  patient  commits  many  breaches  of  decorum, 
and  later,  with  the  degeneration  of  ethical  feeling-  and  the  ascendancy 
of  coarser  instincts,  may  become  very  negligent,  indecent,  and  unclean 
in  habits;  may  pilfer  and  destroy  things;  may  expose  his  person,  mas- 
turbate, or  attempt  liberties  with  little  girls,  etc  His  loss  of  judgment 
may  induce  him  to  foolishly  squander  his  money  and  properties. 

Illusions  and  hallucinations  begin  to  manifest  themselves.  They  are 
usually  of  terrifying  cliaracter. 

Delusions  make  their  appearance.  These  are  nearly  always  perse- 
cutory in  nature,  and  arise  either  as  primary  ideas  or  as  the  result  of 
depression  or  on  the  basis  of  hallucination-.  Next  to  delusions  of 
persecution  in  frequency,  we  observe  hypochondriacal  delusions,  with 
contents  modified  by  the  weak-mindedness  present.  Delusions  of  ap- 
proaching poverty  are  quite  common. 

The  underlying  mood  is  often  melancholic  ;  an  exalted  mood  is  ex- 
tremely rare.  Changeability  with  irritability  is  perhaps  the  most  usual 
affective  condition. 

The  behavior  of  these  patients  in  relation  to  night  is  noteworthy. 
Illusions,  hallucinations,  delusions,  and  emotional  states  all  become 
more  pronounced  at  night.  A  striking  feature,  too,  is  extreme  motor 
restlessness,  especially  at  night.  These  patients  try  to  get  up  from 
bed,  to  wander  about  the  house,  to  get  away  from  something  or  some- 
body. Sometimes  true  melancholic  anxious  states  come  on  and  lead  to 
attempts  at  suicide. 

So  far  as  bodily  symptoms  are  concerned,  we  note  foremost  among 
them  a  general  senile  decrepitude,  to  which  are  added  senile  tremor  of 
the  hands,  and  often  various  stigmata  of  focal  lesions  in  the  brain 
(aphasic  and  paraphasic  attacks) ;  sometimes  hemiparesis,  monoplegia, 
hemiplegia,  etc.,  complicate  the  picture.  The  patients  often  complain 
of  severe  pains  all  over  the  body,  of  vertigo,  ringing  in  the  ears,  sparks 
before  the  eyes,  etc.  Often,  too,  there  is  noticeable  diminution  of  sen- 
sibility to  touch  and  pain  in  various  areas,  or  over  the  whole  body. 
Occasionally  an  especial  color  is  given  to  the  symptoms  described  by 
true  maniacal  or  melancholic  phases  appearing  in  the  course  of  the  dis- 
ease. 

Course  and  Prognosis. — Senile  dementia  develops  gradually  upon 
the  basis  of  senile  psychic  degeneration,  and  lasts,  ordinarily,  from 
three  to  five  years,  sometimes  with  remissions  which  are  never  so  note- 
worthy as  the  remissions  of  paralytic  dementia.  In  rare  instances 
an  acute  course  is  taken,  the  disease  terminating  by  death  in  a  few 
months.  Paralytic  attacks  are  not  infrequently  observed  in  the  course 
of  the  malady,  giving  it  a  certain  analogy  to  paresis.  The  prognosis  is 
unfavorable,  as  the  disorder  is  incurable  and  progressive  to  a  fatal  end. 
Diagnosis. — The  most  important  indications  for  diagnosis  are 
defects  of  memory  and  judgment  and  acts  dependent  upon  loss  of 
ethical  feeling. 


728  MENTAL  DISEASES. 

Pathological    Anatomy. — We    observe    at   autopsy    chiefly    the 
following  conditions  : 

1.  Osteophytic  deposits  on  the  inner  surface  of  the  skull. 

2.  Pachymeningitis  hemorrhagica  interna    (more    frequently    even 
than  in  paralytic  dementia). 

3.  Opaque  and  thickened  leptomeninges. 

4.  Increased  fluid,  subdural,  and  in  the  meshes  of  the  pia-arachnoid. 

5.  Distention  of  the  ventricles  with  serum,  and  granular  ependyma. 

6.  Extreme  narrowing  of  the  cortex,  with  gaping  sulci. 

7.  General  endarteritis  deformans  (often  with  foci  of  softening  and 
hemorrhage). 

8.  Wide-spread  degeneration  of  ganglion-cells  and  association  fibers. 
Treatment. — Many  cases  of  senile  dementia  can  be  treated  at  home. 

It  is  only  when  tendencies  to  suicide,  sexual  immoralities,  waste  of 
property,  and  great  ideomotor  excitement  are  exhibited  that  commitment 
is  necessary.  The  bromids  are  the  best  hypnotic  for  these  cases. 
Paraldehyd  is  extremely  useful,  too,  since  it  is  efficient  as  a  hypnotic 
and  does  not  injure  the  circulation  or  aifect  the  digestive  apparatus.  In 
melancholic  phases  opium  acts  well.  Hyoscin  and  its  congeners  are 
not  to  be  recommended  because  of  their  depressing  action  on  the  heart. 


PRIMARY  DEMENTIA. 

Synonyms. — Acute  dementia  ;  Acute  curable  dementia  ;  Stupiditas. 

Definition. — Primary  dementia  is  an  acute  curable  psychosis  charac- 
terized by  ideomotor  inhibition  and  apathy.  The  inhibition  of  thought 
may  attain  to  the  degree  of  complete  cessation  of  the  psychic  functions, 
and  that  of  motion  to  complete  immobility. 

Etiology. — This  is  essentially  a  disorder  of  youth.  A  rare  disease 
in  itself,  it  is  chiefly  encountered  in  young  persons  between  the  ages  of 
puberty  and  thirty  years.  After  thirty-five  it  is  extremely  infrequent. 
A  neuropathic  constitution  is  found  in  some  sixty  per  cent,  of  the  cases. 
Any  mental  or  physical  stress  that  induces  exhaustion  of  the  nervous 
system  may  act  as  an  exciting  cause  of  primary  dementia.  Fright,  con- 
cussion of  the  brain  from  trauma,  hemorrhages,  frequent  child-bearing, 
physical  and  mental  overwork  or  overexertion,  and  masturbation  have 
all  been  cited  as  etiological  factors. 

Symptomatology. — The  development  of  the  malady  is  gradual. 
At  first  there  is  difficult  concentration  of  the  thoughts  with  loss  of  in- 
terest in  everything  and  a  certain  restlessness.  The  patient  perceives  a 
lack  of  energy  in  his  idea-associations  ;  nothing  suggests  thoughts  to  him, 
and  he  begins  to  feel  a  sort  of  depressed  wonder  at  his  own  condition. 
Complicated  processes  of  thought  become  impossible,  and  even  the 
simplest  concrete  memory-pictures  are  difficult  of  recollection.  He  can 
not  recall  the  countenances  of  his  friends,  the  position  of  the  furniture  in 
his  room,  the  situation  of  his  home,  the  events  of  the  past  or  of  yesterday. 
He  feels  his  head  empty  of  ideas.  Things  seem  to  grow  distant ;  voices 
sound  far  away.     The  senses  become  blunted  and  respond  at  first  slowly, 


DEMENTIA.  ~2'.i 

later  not  at  all,  to  stimuli.  The  patient  sinks  deeper  and  deeper  into 
a  dream-state.  His  face  becomes  expressionless,  his  eyes  staring  into 
vacancy.  He  makes  no  response  to  questions.  He  pays  no  attention  to  his 
surroundings,  to  his  dress,  to  his  physical  needs.  He  grows  anesthetic 
and  analgesic.  The  cutaneous  reflexes  are  markedly  diminished.  The 
pupils  are  widely  dilated,  and  react  but  sluggishly.  The  tendon-reflexes 
are  exasperated.  There  are  no  delusions,  hallucinations,  or  illusions,  as 
a  rule,  though  in  some  rare  instances  there  may  be  some  transient  mani- 
festation of  such  symptoms.  The  immobility  is  flaccid  in  character, 
only  seldom  presenting  any  indication  of  spastic  tension.  For  hours 
and  days  he  will  stand,  sit,  or  lie  in  one  place.  He  is  usually  speech- 
less, but  if  an  attempt  is  made  to  utter  an  interjection  or  phrase,  the 
voice  is  so  low  as  to  be  little  more  than  the  movement  of  the  muscles  of 
articulation.  The  pulse  is  small  and  weak,  the  heart-action  retarded, 
the  temperature  subnormal,  the  respiration  shallow. 

A  peculiar  feature  of  the  condition  is  the  occurrence  of  sudden  epi- 
sodic periods  of  excitement,  with  a  certain  amount  of  exaltation  lasting 
an  hour  or  two,  in  which  the  patient  runs  about,  sings,  dances,  and  talks 
incoherently. 

There  are  forms  of  primary  dementia  which  are  more  or  less  compli- 
cated with  melancholia,  stuporous  paranoia,  and  neurasthenia. 

Course  and  Prognosis. — The  psychosis  lasts  from  a  few  months  to  a 
year  or  more,  and  about  three  in  five  gradually  recover.  Most  of  those 
who  recover  show  a  defect  of  memory  for  what  has  occurred.  Some 
cases  recover  incompletely,  and  some  undergo  an  imperceptible  tran- 
sition into  secondary  dementia. 

Diagnosis. — The  chief  difficulty  in  diagnosis  lies  in  the  differentia- 
tion of  apathetic  forms  of  melancholia  from  primary  dementia.  From 
the  expression,  attitude,  gestures,  and  speech,  one  determines  the  exist- 
ence of  the  anxious  state  or  hallucinations  which  lie  at  the  base  of 
melancholia  passiva  or  melancholia  attonita.  The  history  of  the 
patient  will  distinguish  congenital  or  acquired  idiocy  from  this  form 
of  insanity. 

Pathological  Anatomy. — No  physical  basis  has  been  established 
for  this  disease.     It  is  regarded  as  a  purely  functional  psychosis. 

Treatment. — Mild  cases  may  be  treated  at  home  under  propitious 
conditions.  At  the  same  time,  most  of  these  patients  are  better  off  in 
asylums,  where  the  discipline,  regular  life,  and  expert  care  favor  speedy 
recovery.  Rest  in  bed  and  overfeeding  are  requisite  at  first.  Regular 
hydrotherapeutic  measures  are  of  value  (at  first  short  warm  baths,  later 
on  showers  and  spinal  douche).  Medicines  are  of  no  especial  value 
except  in  the  episodic  periods  of  excitement,  when  the  bromids  may  be 
employed,  together  with  hot  wet-packs. 


730  MENTAL  DISEASES. 


CHAPTER  XI. 
PARALYTIC  DEMENTIA. 

Synonyms. — Dementia  paralytica  ;  Progressive  general  paralysis  ;  General  paresis  ;. 
G-eneral  paralysis  of  the  insane. 

Definition. — Paralytic  dementia,  as  its  name  implies,  is  a  disorder 
characterized  chiefly  by  progressive  enfeeblement  of  the  mind,  together 
with  a  progressive  general  paralysis  of  the  whole  body.  It  is  essen- 
tially a  cortical  disease,  but  its  symptomatology  is  frequently  modified 
by  spinal  complications.  The  psychic  symptoms,  in  addition  to  the 
characteristic  progressive  dementia,  present  multiform  phases,  neu- 
rasthenic, hysterical,  hypochondriacal,  melancholic,  maniacal,  circular, 
paranoiac,  etc.  An  expansive  phase  with  delusions  of  grandeur  is  very- 
common  at  one  period  or  another  in  the  course  of  the  malady. 

Etiology. — Intellectual  overwork  or  strain,  working  on  a  founda- 
tion impaired  by  syphilis  or  alcoholism,  or  both,  may  be  said  to  be  the 
chief  cause  of  general  paresis.  Heredity,  undoubtedly,  plays  a  part  in 
the  causation  of  this  form  of  mental  disorder,  though  perhaps  not  so 
great  as  in  other  classes  of  insanity.  The  role  of  heredity  has  been 
variously  computed  at  from  ten  to  forty  per  cent.  As  regards  sex,  it  may 
be  stated  that  on  an  average,  among  all  classes  of  society,  twelve  times  as 
many  males  as  females  are  affected — the  disproportion  seems  to  be  less 
among  lower  orders  of  people.  The  age  of  onset  is  usually  during  the 
fourth  or  fifth  decad,  bespeaking  in  general  the  climacteric  period  of 
human  life.  But  general  paralysis  may  be  encountered  at  almost  any 
age.  Some  fifty  cases  have  been  recorded  as  occurring  in  children. 
Occasionally  late  cases  are  met  with  after  the  age  of  sixty.  It  is  a 
common  disease  in  the  great  centers  of  civilization,  where  the  intellec- 
tual stresses  are  most  severe,  and  is  comparatively  rare  among  lower 
races.  For  instance,  it  is  almost  never  observed  among  the  native 
Egyptians.1  The  disease  is  more  frequent  among  men  of  ability  in 
professional  or  business  life  than  among  the  ignorant  and  uncultured. 

As  regards  the  position  of  syphilis  as  an  etiological  factor,  it  may  be 
said  that  a  certain  history  of  syphilis  is  obtainable  in  at  least  fifty  per 
cent,  of  the  cases,  and  it  is  probable  that  the  true  relation  is  considera- 
bly larger.  Several  years  ago,  in  a  study  of  this  subject,2  I  examined 
the  contributions  of  no  fewer  than  seventy  authors  to  the  elucidation  of 
this  problem.  There  was  wide  divergence  in  the  statistics  presented  ; 
but  from  my  examination  of  all  these  figures,  it  is  fair  to  assume  that 
between  sixty  and  seventy  per  cent,  of  all  cases  of  general  paralysis 
are  probably  syphilitic. 

By  a  comparison  of  statistics  of  the  relation  of  syphilis  to  all  other 

luThe  Insane  in  Egypt,"  by  the  author,  "Med.  Record,"  1892. 

2  "The  Relation  of  Syphilis  to  General  Paresis,"  "  Medical  Record,"  Dec.  9,  1893. 


PARALYTIC  DEMENTIA.  73] 

forms  of  insanity,  which  I  have  estimated  to  be  from  six  to  ten  per 
cent.,  we  have  the  further  fact  that  syphilis  is  seven  to  ten  times  as  fre- 
quent in  dementia  paralytica  as  in  insanity  in  general. 

The  fact  is  thus  established  beyond  dispute  that  syphilis  is  a  striking 
etiological  factor  in  general  paresis,  but  that  thirty  to  forty  per  cent. 
of  the  cases  are  not  syphilitic.  It  is,  therefore,  an  important,  but  aot 
exclusive,  etiological  factor. 

A  much  more  difficult  problem  is  to  determine  the  exact  nature  of 
the  relationship  between  syphilis  and  general  paresis.  Is  it  a  direct 
cause,  or  merely  a  contributing  agent?  Is  it  in  syphilitic  cases  a  post- 
syphilitic affection,  or  is  foregone  syphilis  merely  a  predisposing  factor? 
The  problem  may  be  examined  from  several  standpoints.  In  the  first 
place,  we  have  the  rather  remarkable  statistics  of  Lewin  of  20,000 
cases  of  syphilis,  one  per  cent,  of  which  became  insane,  and  in  which 
not  a  single  case  of  general  paresis  developed.  Then  we  have  the 
further  fact,  to  which  I  have  already  alluded,  that  among  the  native 
Egyptians,  where  syphilis  is  one  of  the  most  wide-spread  of  disorders, 
scarcely  a  case  of  general  paresis  has  been  reported  ;  and  in  the  asylums 
at  Cairo,  which  I  visited  a  few  years  ago,  not  one  such  case  was  to  be 
found.  It  is  significant,  by  the  way,  that  alcoholism  is  seldom  or  never 
observed  among  them,  the  drinking  of  spirituous  liquors  being  inter- 
dicted by  the  Koran.  Such  facts  as  these  it  is  impossible  to  reconcile 
with  a  hypothesis  ascribing  to  syphilis  the  direct  causation  of  paralytic 
dementia. 

Again,  from  the  pathological  standpoint,  it  is  well  known  that  the 
direct  invasion  of  the  brain  by  syphilis  is  characterized  by  changes  in 
the  blood-vessels  (endarteritis  obliterans),  by  the  formation  of  gum- 
mata,  or  by  diffuse  meningeal  infiltration  (specific  leptomeningitis  or 
meningo-encephalitis).  The  first  and  third  of  these  processes  are  most 
frequent  in  and  about  the  base  of  the  brain.  The  second  is  more  com- 
mon in  cortical  regions.  On  the  other  hand,  in  general  paralysis  we 
have  a  chronic  meningitis  of  the  convexity  with  atrophy  of  the  cortex, 
and  the  processes  in  this  disease  and  in  syphilis  are  quite  distinct, 
although  there  are  cases  in  which  a  syphilitic  meningo-encephalitis  may 
closely  simulate  symptomatically  dementia  paralytica.  The  pathological 
processes  are  different. 

There  are  some  who  assume  that  tabes  and  general  paresis  are  fre- 
quently associated,  and  that  tabes,  being  so  decidedly  a  syphilitic  disease 
(ninety  per  cent),  general  paresis  must,  in  consequence,  originate  from 
syphilis.  The  first  part  of  this  assumption  is,  however,  not  true ;  and 
if  it  were,  there  is  a  singular  lack  of  correspondence  between  the  per- 
centages of  syphilis  in  the  etiological  statistics  of  the  two  diseases.  The 
conclusions  reached  by  the  writer  in  the  study  just  referred  to  are  as 
follows  : 

1.  A  history  of  syphilis  is  found  in  sixty  to  seventy  per  cent,  of 
cases  of  general  paralysis  of  the  insane. 

2.  The  fact  must  not  be  lost  sight  of  that  in  thirty  to  forty  per  cent, 
of  these  cases  no  history  of  syphilis,  congenital  or  acquired,  is  to  be 
found. 


732  MENTAL  DISEASES. 

3.  Antecedent  syphilis  is  seven  to  ten  times  more  frequent  in  general 
paralysis  than  in  other  forms  of  insanity. 

4.  Syphilis  is,  therefore,  to  be  looked  upon  as  a  frequent,  but  not 
constant,  factor  in  its  production. 

5.  But  paralytic  dementia  is  not  a  form  of  specific  disease,  not  a  late 
syphilitic  manifestation,  nor  is  it  a  form  of  degeneration  depending  upon 
the  syphilitic  poison  for  its  origin. 

6.  The  relationship  of  syphilis  to  general  paresis  lies  in  the  facts 
that  it  is  a  wide-spread  disorder  in  all  communities,  that  it  weakens  the 
constitution  and  vitiates  the  blood  in  many  whom  it  infects,  and  that 
the  system  is  thus  prepared  in  many  cases  for  the  direct  operation  of  the 
final  etiological  factors  of  general  paresis — viz.,  alcoholism,  excessive 
venery,  heredity,  and  mental  overstrain  and  excitement. 

Alcohol  would  seem  to  be  a  factor  in  some  twenty  per  cent,  of  par- 
etics. Other  toxic  agents  (lead,  tobacco,  rheumatism,  etc.)  are  also  be- 
lieved to  take  a  part  at  times  in  the  etiology.  Trauma  has  often  been 
mentioned  as  an  occasional  cause  of  paresis,  but  there  is  no  well-authen- 
ticated instance  in  literature  of  such  etiology,  and  until  better  evidence 
is  offered  we  must  doubt  the  sufficiency  of  this  factor. 

In  most  cases,  as  already  intimated,  several  of  the  causes  named  are 
associated  in  the  production  of  the  disease. 

Symptomatology. — The  disease  is  best  studied  in  its  three  stages 
— the  prodromal  period,  the  established  disorder  (which  may  be  exalted, 
depressed,  or  hallucinatory),  and  the  terminal  period  of  dementia. 

Prodromal  Period. — General  paresis  is  one  of  the  most  insidious 
forms  of  insanity  as  regards  its  gradual,  almost  unnoticeable  onset. 
Very  often  this  early  stage  presents  symptoms  which  lead  to  its  being 
mistaken  for  neurasthenia.  Indeed,  the  earliest  symptoms  may  be 
neurasthenic  in  character,  or  even  a  combination  of  hysteria  with  neu- 
rasthenia. Sleeplessness,  tremor,  irritability  of  mood,  hypochondriacal 
depression,  dull  headache,  ophthalmic  migraine,  pains  in  various  parts 
of  the  body,  general  malaise,  loss  of  appetite,  and  digestive  disorders — 
these  are  the  manifestations  which  may  be  readily  misinterpreted  as 
purely  of  functional  nature.  It  is  only  when  other  symptoms  in  ad- 
dition to  these  are  presented  that  a  suspicion  of  a  more  serious  malady 
may  be  entertained  or  the  diagnosis  actually  established.  These  symp- 
toms are,  on  the  mental  side  :  little  faults  of  memory  ;  errors  in  speech  or 
writing ;  the  misuse  of  words  ;  the  leaving  out  of  letters,  syllables,  or 
words,  or  their  reduplication  in  writing ;  growing  indifference  to  the 
higher  sentiments  ;  loss  of  the  critical  faculty ;  small  lapses  in  the  pro- 
prieties, and  failure  of  interest  in  the  more  important  affairs  of  life.  As 
these  mental  features  become  more  and  more  pronounced,  the  patient 
loses  and  mislays  things,  makes  mistakes  in  money  matters,  errs  in  ap- 
pointments, confuses  persons  and  objects,  forgets  his  way,  becomes 
easily  angered,  markedly  offends  the  proprieties,  shows  extravagance  in 
the  use  of  money,  evinces  distinct  loss  of  the  ethical  feelings,  exhibits 
proclivities  to  sexual  and  alcoholic  excess,  and  becomes  negligent  of  his 
dress. 

In  the  earlier  period  the  patient,  like  any  neurasthenic,  has  a  dis- 


PA  It  A  L  YTIC  DEMENTIA .  J:  Hi 

tinct  consciousness  of  his  own  illness  and  observes  his  symptom.-.  lint 
with  the  progress  of  the  malady — and  it  is  in  this  that  we  find  an  im- 
portant contrast  to  the  course  of  neurasthenia — he  loses  that  sense  of 
being  ill,  takes  no  further  notice  of  his  own  symptoms.  On  the  physical 
side  there  are  a  number  of  significant  marks  which  are  helpful  in  mak- 
ing an  early  diagnosis:  defective  innervation  of  one  side  of  the  face. 
causing  a  slight  paralysis  ;  transitory  ocular  palsies,  diminished  sensibility 
to  pain,  Argyll-Robertson  pupils ;  diminished,  lost,  or  exaggerated 
tendon-reflexes  ;  a  dark,  pale,  greasy  complexion  ;  lack  of  facial  expres- 
sion ;  jerky  tremor  of  the  faciolingual  muscles  at  the  beginning  of 
voluntary  movement;  slight  difficulties  of  articulation;  rushings  of 
blood  to  the  head,  and  attacks  of  syncope  or  of  mild  or  severe  epilepti- 
form convulsions.  A  number  of  other  early  symptoms  have  been 
described  by  various  authors  to  which  some  value  attaches  :  loss  of 
memory  of  localization  of  tactile  sensations  (Ziehen)  ;  loss  of  the 
cremasteric  reflex ;  testicular  insensibility;  peculiar  respiration,  with 
short  inspirations,  followed  from  time  to  time  by  prolonged  sighing 
expirations  (Regis) ;  gastric  and,  vesical  crises  (Hurd) ;  calcification  of 
the  sternum,  with  incurvation  of  the  xiphoid  appendix  and  consequent 
interference  with  thoracic  breathing  (Regis). 

Period  of  Establishment  of  the  Disease. — When  the  disorder  is 
fully  established  after  a  prodromal  period  which  may  range  over  months 
or  years,  it  is  marked  by  both  physical  and  mental  symptoms  which  are 
usually  characteristic  : 

Chief  Physical  Symptoms. — (1)  Peculiar  articulation  and  writ- 
ing— the  "  paretic  speech  "  and  "  paretic  writing  "  ;  (2)  tremor  ;  (3) 
pupillary  disorders  ;  (4)  lost  or  exaggerated  tendon-reflexes ;  (5)  mus- 
cular weakness  ;  (6)  apoplectiform  and  epileptiform  crises  ;  (7)  emacia- 
tion ;  (8)  trophic  disorders. 

Mental  Symptoms. — (1)  Failure  of  memory  for  both  recent  and 
old  events ;  (2)  diminishing  number  of  concrete,  abstract,  special  and 
general  ideas  ;  (3)  weakening  of  judgment ;  (4)  loss  of  sense  of  time 
and  place  (lack  of  orientation) ;  (5)  delusions  (marked  by  enormous 
exaggeration,  whether  exalted  or  depressed) ;  (6)  hallucinations  and  illu- 
sions ;  (7)  emotional  irritability  ;  (8)  exalted,  sometimes  depressed, 
mood ;  (9)  loss  of  ethical  and  esthetic  feeling. 

We  will  now  examine  these  symptoms  somewhat  in  detail. 

The  paretic  speech  is  so  characteristic  that,  heard  a  few  times,  it  is 
always  remembered  ;  yet  it  is  difficult  to  describe.  There  are  shades 
of  difference  in  various  individuals,  so  that  authors  qualify  the  disorder 
of  speech  as  drawling,  stammering,  hesitating,  scanning,  spasmodic, 
ataxic,  and  so  on.  It  has  some  resemblance  to  the  speech  of  a  drunken 
man.  Doubtless  the  main  seat  of  the  lesion  affecting  the  speech  of  the 
paretic  is  in  the  cortical  motor  speech-center,  but  sometimes  the  lesion 
is  probably  in  the  bulbar  centers  connected  with  the  elaboration  of  the 
motor  impulses  requisite  to  articulation.  The  jerky  tremor  or  ataxia 
of  the  speech-muscles,  together  with  incoordinated  impulses  from  the 
cortical  motor  speech-center,  is  responsible  for  the  peculiarities  in 
speech.     Labials  and  certain  consonants  are  the  most  difficult  for  the 


734  MENTAL   DISEASES. 

paretic  to  enunciate,  and  the  typical  speech  is  shown  in  the  attempt  to 
pronounce  such  words  or  phrases  as  "  electricity,"  "  artillery  and  cav- 
alry brigade,"  "  immovability,"  etc.,  in  which  the  consonants  may  be 
left  out,  drawled  over,  misplaced,  or  even  reduplicated  thus  :  "  elec- 
tericity,"  "  artillililery,"  "  bigrade,"  "  immobilty."  As  the  disease 
advances,  the  words  are  run  more  and  more  together,  until  finally  the 
speech  is  utterly  incomprehensible. 

The  handwriting  of  the  patient  is  of  equal,  and  in  the  earliest 
stages  even  of  greater,  importance.  Lapses  of  words,  repetitions  of 
words  or  even  sentences,  and  especially  elisions  and  reduplications  of 
letters  or  syllables  are  extremely  significant. 

The  tremor  in  paretics  affects  all  parts  of  the  body,  but  is  especially 
noteworthy  in  the  face  and  tongue.  In  the  tongue  it  often  takes  on  a 
fine,  fibrillary  character.  It  is  very  rare  in  even  pronounced  neuras- 
thenic conditions  to  observe  tremor  of  the  facial  muscles.  Still  we  do 
meet  with  it  at  times,  and  the  distinction  that  I  would  draw  between 
the  facial  tremor  of  profound  neurasthenia  and  that  of  paresis  is  that 
in  the  latter  disorder  there  is  a  peculiar  jerkiness  and  ataxia  in  the 
tremor,  especially  at  the  beginning  of  a  voluntary  movement.  Thus,  in 
asking  the  paretic  to  wrinkle  his  forehead,  an  ataxic  tremor  will  be  set 
up  in  the  occipitofrontalis.  In  snarling  up  the  nose,  it  is  observed  in 
the  small  muscles  about  the  cheek  and  nose.  In  showing  the  teeth,  the 
ataxic  tremor  becomes  marked  in  the  levators  of  the  lip.  In  protrud- 
ing the  tongue,  there  is  a  rapid,  jerky  tremor  at  the  beginning  of  the 
movement. 

As  regards  the  pupils,  the  most  important  sign  is  absence  of  the 
reflex  to  light.  Next  in  order  comes  extreme  miosis  (pin-hole  pupils), 
and  next  in  importance  a  variable  inequality  (one  pupil  being  larger  at 
one  time  and  the  other  at  another  time).  Irregularity  of  outline  of 
either  or  both  pupils  is  significant.  Simple  inequality  of  the  pupils  is 
less  distinctive  because  met  with  in  other  forms  of  insanity,  and  occa- 
sionally in  normal  persons.  Marked  mydriasis  is  very  common  in  the 
latest  stage  of  the  disease. 

In  tabic  forms  of  the  disorder  the  knee-jerks  are  diminished  or  lost. 
In  all  other  forms  the  tendon-reflexes  are  apt  to  be  enormously  exag- 
gerated, so  that  we  get  not  only  extreme  knee-jerks,  but  quadriceps 
clonus,  ankle-clonus,  jaw-jerk,  jaw-clonus,  and  extreme  wrist-  and  elbow- 
jerks.  With  this  spastic  condition  we  observe  also  considerable  rigidity 
of  the  muscles,  with  a  tendency  in  the  latest  stage  to  marked  contrac- 
tures. Often  in  tabic  forms,  when  the  knee-jerks  are  at  first  lost,  they 
become  finally  exaggerated.  Hence,  while  the  term  tabic  is  often  used 
to  describe  a  form  of  paresis  in  which  we  have  lost  or  diminished  knee- 
jerks,  together  with  Argyll-Robertson  pupils,  this  is  simply  a  descriptive 
designation,  and  does  not  necessarily  imply  that  we  have  a  combination 
of  locomotor  ataxia  with  paresis. 

As  previously  stated,  one  of  the  chief  symptoms  of  paralytic  de- 
mentia is  a  progressive  weakening  of  the  muscles  in  general  of  the 
whole  body.  It  is  rather  an  enfeeblement  than  a  paralysis.  It  is 
manifested  mainly  by  localized  pareses  in  various  muscles  or  groups  of 


PARALYTIC  DEMENTIA.  735 

muscles.  These  are  often  noted  as  early  symptoms — for  instance,  in  the 
eyes  and  face.  In  fully  one-half  of  the  case:-  we  observe,  at  one  time 
or  another,  weakness  of  some  of  the  ocular  muscles,  not  infrequently 
giving  rise  to  diplopia  or  ptosis,  rarely  nystagmus.  A  certain  amount 
of  ptosis  is  often  seen,  and  the  overaction  of  the  occipitofrontalis  in 
consequence  forms  a  striking  picture  in  many  cases.  One-sided  paresis 
•of  the  forehead  muscle,  orbicularis  palpebrarum,  <>r  Lower  face  is  rather 
common.  The  muscles  about  the  mouth  are  particularly  often  involved, 
so  that  marked  inequality  of  the  nasolabial  fold  and  of  all  of  the  oral 
movements  is  encountered.  The  speech  has  frequently  a  nasal  tone 
from  one-sided  or  double  palate  paralysis.  Deviation  of  the  tongue  is 
common.  The  general  strength  of  the  extremities,  as  measured  by  dyna- 
mometers, is  diminished,  sometimes  on  one  side  more  than  on  the  other, 
presenting  the  picture  of  a  hemiparesis.  The  want  of  equal  innervation 
is  sometimes  indicated  by  the  attitude  of  the  patient,  the  inclination  of 
the  body  to  one  side  or  another,  backward  or  forward,  sinking  of  the 
head  on  the  breast,  etc.  Weakness  in  the  muscles  of  deglutition  leads  to 
difficulty  in  swallowing.  The  peculiarity  of  most  of  these  paralytic  phe- 
nomena is,  in  the  first  place,  their  mildness  of  degree,  and,  in  the  second, 
their  frequently  transitory  character  (the  weakness  may  be  first  on  one 
side  of  the  face,  then  on  the  other,  now  about  one  eye,  now  in  an  ex- 
tremity, etc.). 

Nearly  every  case  of  general  paresis  exhibits,  at  some  time  in  its 
course,  convulsive  or  apoplectiform  seizures.  Usually  these  critical 
episodes  occur  at  the  height  of  the  disorder  or  in  its  final  stages,  but 
occasionally  they  are  among  the  very  earliest  symptoms.  For  instance, 
one  case  that  came  under  my  observation  began  with  a  transitory  hemi- 
plegia following  an  apoplectiform  attack.  Up  to  the  day  before  this 
seizure  he  had  performed  his  difficult  duties  as  an  accountant  in  a  large 
railroad  organization  to  the  perfect  satisfaction  of  his  superiors,  and 
none  of  his  family  had  observed  any  indication  of  prodromal  symptoms. 
He  died  as  a  typical  paretic  a  year  later.  Another  case,  much  the  same 
in  many  ways,  began  with  general  epileptiform  convulsions  extending 
over  twenty-four  hours.  The  attacks  may  appear  in  the  form  of  syn- 
cope, or  coma,  or  aphasia.  A  peculiarity  of  all  of  these  crises  is  their 
transient  character,  and  as  even  in  cases  terminating  fatally  in  such 
attacks  often  no  lesion  has  been  found,  their  pathogeny  has  been 
ascribed  to  congestive  conditions  or  to  circumscribed  edemata  in  various 
areas  of  the  brain.  As  a  rule,  mental  failure  becomes  more  apparent 
after  these  crises. 

Rapid  emaciation  is  usual  after  the  disorder  has  actually  set  in, — that 
is,  at  the  termination  of  the  prodromal  period, — but  later  on,  after  the 
climax  has  been  reached  and  dementia  becomes  more  apparent,  patients 
often  gain  largely  in  flesh. 

Among  the  trophic  disorders  we  note  especially  bed-sores,  which 
appertain  mostly  to  the  terminal  condition.  In  some  of  the  cases  a  true 
trophoneurosis  is  the  cause,  and  in  others  weakened  peripheral  circula- 
tion and  uncleanliness.  A  striking  fragility  of  the  bones  is  common  in 
general  paresis,  which  accounts  for  numerous  accidents  in  asylums,  such 


736  MENTAL  DISEASES. 

as  fractures  of  the  ribs  and  other  bones,  exploited  so  often  in  the  news- 
papers as  due  to  the  assaults  of  attendants.  I  have  known  a  maniacal 
paretic  to  break  all  of  the  small  bones  of  his  hand  by  pounding  on  a 
door.  Hematoma  of  the  ear  is  very  frequent  in  paralytic  dementia, 
and  this  must  be  ascribed  to  trophic  changes  in  the  vascular  walls,  per- 
mitting some  trivial  trauma  to  cause  a  rupture  in  the  vessels  of  the  peri- 
chondrium. The  hair  frequently  becomes  rapidly  gray  in  paresis,  and 
this,  too,  is  doubtless  a  trophic  symptom. 

Among  other  physical  symptoms  occasionally  met  with  are  to  be 
mentioned  changes  of  temperature,  alluded  to  in  the  chapter  on  General 
Symptomatology,  intermittent  albuminuria,  propeptonuria,  glycosuria, 
acetonuria,  polyuria,  impotence,  and  vesical  and  rectal  weakness.  Gly- 
cosuria is  sometimes  an  early  symptom. 

As  regards  mental  symptoms,  the  gradual  and  progressive  failure  of 
memory,  and,  as  a  consequence,  the  progressive  depletion  of  the  store 


Fig.  278. — A  group  of  paretics.    Taken  to  show  exalted  and  melancholic  phases  (Dr.  Atwood). 

of  memory-pictures,  ideas,  idea-associations,  and  judgment-associations, 
are  the  most  noteworthy  features  of  the  disease.  The  most  complicated 
conceptions,  as  well  as  those  acquired  latest,  are  the  first  to  disappear. 
Abstract  ideas,  owing  to  their  complexity,  are  the  earliest  to  go.  The 
patient  loses  his  memory  for  dates,  for  the  events  of  to-day  and  yester- 
day, and  finds  difficulty  in  remembering  his  appointments  and  duties. 
A  very  early  loss  of  the  power  of  mental  computation  is  notable.  With  the 
progress  of  the  malady,  even  the  older  memories  and  concrete  ideas 
vanish  by  degrees.  The  patient  comes  to  have  no  knowledge  of  time, 
the  place  where  he  is,  or  of  the  friends  who  surround  him.  The  loss 
of  the  faculty  of  judgment  is  evident  at  an  early  period  in  his  failing 
observation  and  comprehension  of  his  own  symptoms.  Ordinarily 
there  is  a  retardation  of  the  flow  of  ideas,  particularly  marked  in  the 
melancholic  type  of  the  disease.  In  the  exalted  type  there  is  an  accel- 
eration of  the  flow  of  thought,  which  is  given  a  special  color  by  the 
mental  enfeeblement. 


PARALYTIC  DEMENTIA.  I'M 

There  are  cases  which  run  their  course  without  delusions,  the  symp- 
toms then  being  merely  the  progressive  dementia  with  advancing  physi- 
cal debility.  But  in  a  considerable  proportion  of  paretics  delusione 
arc  manifested,  usually  of  grandiose  character,  associated  with  more  or 
less  ideomotor  excitement  (sometimes  approaching  the  maniacal  condi- 
tion), and  occasionally  of  melancholy  character.  The  grandiose  ideas 
of  male  patients  are  concerned  with  wealth,  power,  glory,  size,  strength, 
position,  possessions,  and  of  female  patients  with  dress,  finery,  jewels, 
and  children.  At  an  early  period  these  grandiose  ideas  are  not  to  !)<• 
distinguished  from  the  similar  fancies  of  many  cases  of  ordinary  acute 
mania.  But  when  the  judgment  becomes  weakened,  as  it  inevitably 
does,  a  peculiarly  distinctive  character  is  given  to  the  paretic's  delu- 
sions. The  grandiose  delusions  take  a  magnitude,  an  enormity,  a  .-tu- 
pendousness  not  observed  in  any  other  form  of  insanity.  Wealth  is 
counted  in  decillions  of  worldfuls  of  gold.  The  patient  is  czar,  king, 
president,  queen,  God,  at  the  same  time.  His  penis  is  a  mile  long, 
his  testicles  large  diamonds.  He  will  bring  the  Pacific  Ocean  over 
the  Andes  to  make  the  largest  waterfall  in  the  world.  He  will 
move  the  asylum  buildings  on  a  road  of  gold  to  Washington.  He 
has  thousands  of  wives,  every  one  of  whom  bears  two  hundred  children 
nightly.  He  bestows  on  his  physicians  and  nurses  royal  orders,  duke- 
doms, writes  them  checks  for  enormous  sums  of  money,  etc.  "When 
the  mood  of  the  patient  is  hypochondriacal  or  melancholic,  the  delu- 
sions retain  the  same  element  of  enormity  despite  their  unhappy 
contents.  He  states  that  he  is  impoverished  by  having  lost  billions  of 
dollars ;  he  is  committed  to  prison  for  thousands  of  years ;  he  weeps 
because  he  can  not  do  his  duty  to  the  nations  which  he  governs ;  there 
is  some  horrible  condition  of  his  bowels  which  requires  the  most  awful 
of  operations,  etc. 

There  are  some  cases  of  general  paresis  which  exhibit  alternating 
phases  of  melancholic  depression  and  ambitious  exaltation,  and  these  are 
described  as  paralytic  dementia  of  circular  type. 

Hallucinations  and  illusions  are  frequently  observed  in  general 
paresis.  They  have  more  or  less  relation  to  the  condition  of  exaltation 
or  depression  present  and  to  the  delusions  manifested.  Auditory  hallu- 
cinations are  the  most  common.  They  are  noted  even  in  the  early 
periods  of  the  disease,  but  are  generally  a  part  of  the  maximum  period. 
They  are  absent  in  the  final  stage. 

Emotional  irritability  and  changeability  are  generally  evident.  The 
patient  laughs  or  weeps  easily,  and  is  often  readily  angered. 

The  excesses,  sexual  and  alcoholic,  lapses  of  propriety,  etc.,  are  sig- 
nificant of  loss  of  esthetic  and  ethical  sensibility.  He  indulges  him- 
self freely  and  without  morality  (though  previously  moral),  drinks  im- 
moderately, steals,  and  squanders  his  own  and  others'  property.  As 
his  character  sinks  lower  and  lower  he  commits  all  sorts  of  shameless 
offenses  against  decency. 

Before  passing  on  to  the  final  stage,  we  not  infrequently  encounter, 
in  the  course  of  the  disorder,  peculiar  interludes  of  recession  of  all  of 
the  symptoms.  These  are  known  as  remissions.  Remissions  last  from 
47 


738 


MENTAL  DISEASES. 


several  weeks  to  several  months,  as  a  rule,  occasionally  for  a  year  or 
more.  Very  striking  at  times  is  the  remarkable  improvement  to  be 
observed  in  a  remission.  This  may  attain  to  a  degree  making  it  almost 
impossible  to  discover  any  vestige  of  deviation  from  the  patient's  normal 
mental  health.  The  extraordinary  delusions  disappear,  the  maniacal  or 
melancholic  mood  vanishes,  the  symptoms  of  confusion  and  forgetfulness 
pass  away,  and  noteworthy  intellectual  lacunae  are  filled  again.  The 
patient  may  return  to  his  affairs.  It  is  very  rarely  that  marked  physi- 
cal stigmata  of  the  disorder  diminish  and  give  place  to  normal  con- 
ditions. After  a  time  the  old  symptoms  of  the  dread  malady  reassert 
themselves  and  its  fatal  progress  is  rebegun. 

Terminal  Period. — As  already  intimated,  there  are  cases  in  which 

there  is  merely  a  progressive  en- 
feeblement  of  mind  and  paresis  of 
body  from  beginning  to  end,  with 
none  of  the  excited  or  depressed 
conditions,  delusions,  hallucinations, 
remissions,  etc.,  just  described  ;  cases 
which  pass  by  gradual  stages  from 
the  prodromal  into  the  terminal 
period.  In  the  main,  however,  we 
have  most  of  these  other  manifesta- 
tions interpolated.  The  final  stage 
is  often  ushered  in  by  the  convul- 
sive or  apoplectiform  seizures.  This 
is  the  stage  of  more  or  less  com- 
plete dementia.  We  may  still  note 
the  remains  of  old  grandiose  or 
hypochondriacal  delusions  in  the 
scarcely  comprehensible  mumblings 
of  the  paretic  dement,  but  usually 
the  mind  becomes  completely  vacu- 
ous ;  the  patient  speechless,  filthy 
in  his  habits,  bedridden,  and  more 
helpless  than  an  infant.  He  lies  in 
bed,  either  motionless  or  restlessly 
moving  his  limbs  and  grinding  his 
teeth.  He  can  scarcely  swallow  his  food,  and  often  requires  to  be  fed 
to  prevent  strangling.  He  wets  and  soils  himself,  and  bed-sores  and 
contractures  develop.  Finally,  death  by  inhalation-pneumonia,  septi- 
cemia (from  the  bed-sores),  cystitis,  marasmus,  intestinal  catarrh,  or  ex- 
haustion steps  in  to  draw  the  curtain  on  the  distressing  picture.  Not  a 
few  die  at  an  earlier  period  in  an  epileptiform  or  apoplectiform  crisis. 

Duration  and  Prognosis. — Paralytic  dementia  runs  its  course  in 
three  to  five  years,  on  an  average.  There  are  more  cases  which  termi- 
nate under  three  years  than  over  five,  but  cases  lasting  five  years  are 
not  infrequent.  A  duration  of  ten  years  is  among  the  greatest 
rarities. 

The  prognosis  is  practically  always  death  within  a  short  term  of 


Fig.  279. — A  noted  actor  who  recently  died 
of  paresis.  Taken  to  show  the  expression  of 
paralytic  dementia  in  an  unusually  expressive 
face  (loaned  by  Dr.  Atwood). 


PARALYTIC  DEMENTIA. 


739 


years.  The  author  has  never  known  personally  of  a  case  recovering. 
In  our  whole  literature  there  are,  according  to  Ziehen,  but  a  dozen 
cases  of  recovery  on  record.  It  is  probably  questionable  if  even  these 
were  genuine  cases  of  paresis,  since  an  error  in  diagnosis  is  not  at  all 
uncommon. 

Diagnosis. — The  chief  disorders  which  may  be  confused  with 
paralytic  dementia  during  the  various  stages  of  its  evolution  are 
neurasthenia,  alcoholism,  syphilis  of  the  central  nervous  system,  acute 
mania,  epileptic  dementia,  paranoia,  or  secondary  paranoia  with  delusions 
of  grandeur,  multiple  sclerosis,  and  mental  conditions  associated  with 
common  organic  lesions  of  the  brain  (tumor,  hemorrhage,  embolism, 
thrombosis).  In  atypical  cases  the  diagnosis  is  often  difficult  and 
sometimes  even  impossible. 

As  regards  neurasthenia,  it  is  only  in  the  prodromal  period  of  gen- 
eral paralysis  that  differentiation  may  be  difficult.  I  shall  attempt  to 
present  in  brief,  tabular  form  the  distinctive  diagnostic  points  of  these 
two  conditions  : 


General  Paresis  (Early  Period). 

Sluggish,  immobile,  irregular,  pin-hole, 
or  unequal  pupils. 

Diminished,  greatly  exaggerated,  or  un- 
equal knee-jerks. 

Fibrillary  tremor  of  tongue ;  jerky, 
ataxic  tremor  of  fingers,  face, 
tongue,  occipitofrontalis. 

Elision  or  reduplication  of  letters,  syl- 
lables, or  words  in  writing. 

Sometimes  noticeable  characteristic  de- 
fects in  speech. 

Usually  little  or  no  notice  taken  by  the 
patient  of  his  symptoms. 

In  some  cases  a  feeling  of  cheerfulness 
and  well-being  out  of  proportion  to 
the  actual  disorder  present. 

In  many  cases  a  vague,  hypochondriacal 
depression  with  tearfulness,  not 
referred  to  any  definite  physical 
cause. 

Actual  evidence  generally  found  of  fail- 
ing memory,  defect  of  intellectual 
process,  weakened  judgment,  and 
loss  of  esthetic  and  ethical  feeling. 

Occasionally  epileptiform  or  apoplecti- 
form crises. 

Vertiginous  attacks  and  transitory  apha- 
sia of  mild  degree. 


Neurasthenia. 
Large  and  rather  active  pupils  usually. 

Active  and  equal  tendon-reflexes. 

Tremor  fine  and  rapid  of  fingers  and 
eyelids,  not  jerky,  very  rarely  in- 
volving face,  almost  never  the 
tongue  and  forehead. 

Nothing  abnormal  in  the  writing. 

No  changes  in  enunciation. 

Patient  pays  marked  attention  to  his 

symptoms. 
Patient  apprehensive  and   alarmed  at 

any  symptoms  present. 

When  hypochondriacal,  patient's  atten- 
tion fixed  on  some  definite  morbid 
process  which  he  believes  to  be 
going  on  in  his  system. 

No  evidence  of  mental  decay  or  loss  of 
esthetic  and  ethical  feeling. 

Nothing  of  this  kind  in  neurasthenia. 
Not  present  in  neurasthenia. 


In  chronic  alcoholism  we  may  have  presented  to  us  many  symptoms, 
such  as  tremor,  thick  speech,  mental  changes  and  defects,  epileptiform 
crises,  and,  where  rudimentary  polyneuritis  is  present,  lost  knee-jerks, 
which  may  simulate  the  syndrome  of  paralytic  dementia.  The  resem- 
blance is  sometimes  remarkably  close.  The  chief  differential  point  is 
the  great  improvement  and  often  recovery  which  take  place  in  alco- 
holic mental  disorder  on  withdrawal  of  the  alcohol.     With  abstinence 


740 


MENTAL  DISEASES. 


the  speech  becomes  normal,  the  tremor  grows  less  or  disappears,  the 
knee-jerks  return,  epileptiform  attacks  cease,  defects  of  memory  are  no 
longer  perceptible.  If  hallucinations  are  present,  they  are  more  often 
visual  and  zooscopic  in  alcoholism,  while  generally  auditory  in  paresis. 
The  delusions  of  the  chronic  alcoholic  are,  as  a  rule,  suspicious  and  per- 
secutory. It  must  be  remembered  that  a  typical  general  paresis  may, 
however,  develop  on  the  basis  of  a  chronic  alcoholism. 

Aside  from  the  comparison  of  neurasthenia  with  the  prodromal 
period,  probably  the  mistaking  of  syphilis  of  the  central  nervous 
system  for  advanced  general  paralysis  is  the  most  common  error  in 
diagnosis.  The  two  disorders  have  so  much  in  common  that  their 
differentiation  is  often  only  possible  by  prolonged  observation  through 
the  whole  course  of  the  disease ;  and  if  the  paretic  dementia  should 
happen  to  progress  as  a  simple  dementia  with  none  of  the  character- 
istic episodes,  the  diagnosis  is  sometimes  quite  impossible.  The  follow- 
ing table  will  serve  to  make  some  of  the  similar  and  unlike  features  of 
the  two  maladies  apparent  : 


General  Paralysis. 

Paresis  of  mild  degree  of  cranial  nerves 
at  times.  Slow  in  onset  and  trans- 
itory. 

Symptoms  of  a  diffuse  general  lesion. 

Jerky  and  ataxic  tremor. 

Loss  of  iris  reflex  to  light,  preserva- 
tion of  movement  of  iris  in  accom- 
modation (Argyll-Robertson  pupil); 
extreme  miosis. 

Characteristic  elisions  and  reduplications 
of  letters,  syllables,  or  words  in  writ- 
ing. 

Peculiar  disorder  of  speech.  (Gr.  P. 
speech.) 


Headaches  vague,  transitory,  and  sel- 
dom distressing. 

No  material  changes  in  the  fundus. 

Progressive  advance  of  the  disease<  to  a 
speedily  fatal  termination,  with  a 
possible  remission  in  some  instances 
for  a  brief  period. 

Delusions  often  expansive,  sometimes 
depressed,  characterized  by  enor- 
mous exaggeration  in  either  case. 

Affective  state  often  expansive,  some- 
times depressed. 

Progressive  mental  enfeeblement. 

Epileptiform  and  apoplectiform  crises  in 
nearly  every  case,  and  frequently  re- 
peated. 

Antisyphilitic  remedies  useless. 


Cerebrospinal  Syphilis. 

Complete  paralysis  of  one  or  several 
cranial  nerves  often.  Generally  sud- 
den in  onset  and  stable. 

Symptoms  of  multiple  lesions. 

No  tremor  in  syphilis. 

Iris  often  immobile  both  to  light  and  in 
accommodation ;  extreme  miosis 
very  infrequent. 

If  any  change  in  writing  at  all,  due  to 
agraphia  or  dementia.  No  resem- 
blance of  the  changes  to  those  of 
paresis. 

No  speech  disorder  usually,  but,  if  any, 
due  to  organic  aphasias  of  one  kind 
or  another.  No  resemblance  to  the 
Gr.  P.  speech. 

Headaches  extremely  severe,  constant, 
and  worse  at  night. 

Optic  neuritis  occasionally. 

Irregular  advance,  with  many  fluctua- 
tions in  intensity  and  character  of 
the  symptoms,  extending  over  a 
long  period  of  years,  and  not  neces- 
sarily fatal. 

Delusions  rarely  present. 


Affective  state  usually  depressed  or  apa- 
thetic. 

Incoherence  and  thought-inhibition. 

Epileptiform  and  apoplectiform  seizures 
uncommon,  but  if  they  do  occur,  are 
generally  single,  isolated  attacks. 

Antisyphilitic  remedies  of  marked  ser- 


A  gummatous  meningitis  may,  however,  present  a  typical  general 


PARALYTIC  DEMENTIA.  741 

paresis  in  all  its  manifestations,  and  there  arc  cases  in  which  the  aetual 
lesions  of  paresis  exist  side  by  side  with  syphilitic  cerebral  lesions. 

We  may  have  maniacal  outbursts  in  the  course  of  general  paresis. 
Indeed,  I  have  seen  paresis  begin  in  a  number  of  instances  as  an 
apparent  acute  mania.  During  this  maniacal  state  the  chief  means  of 
differentiation  of  the  two  disorders  is  in  the  character  of  the  content-  of 
the  delusions.  Both  are  exalted  and  expansive  and  tend  to  the  same 
general  exaggeration  of  feelings  of  power,  strength,  intellectual  and 
physical  abilities,  wealth,  social  station,  etc.  But  the  stupendous  ex- 
aggeration in  general  paresis  is  never  observed  in  acute  mania.  This  is 
a  valuable  indication.  Naturally,  if  any  of  the  physical  signs  of  paresis 
are  present,  the  diagnosis  is  not  difficult. 

Epileptic  dementia,  with  its  slow  speech,  mental  defect,  and  epileptic 
seizures,  might  at  times  be  mistaken  for  a  paralytic  dementia,  presenting 
chiefly  these  symptoms.  But  the  history  of  long  years  of  epilepsy 
preceding  the  psychic  degeneration  suffices,  as  a  rule,  for  the  diagnosis. 
It  is  only  when  such  history  is  not  obtainable  that  error  might  arise. 

In  paranoia  itself,  and  in  paranoia  secondary  to  acute  mania  or 
melancholia,  the  expansive  or  depressed  delusions  are  of  a  more  fixed 
and  much  less  exaggerated  nature.  A  study  of  the  character  of  the 
delusional  contents  should  make  differentiation  easy. 

Multiple  sclerosis,  with  its  jerky  tremor,  exaggerated  reflexes,  and 
mental  enfeeblement  might  at  times  present  a  syndrome  analogous  to 
that  of  some  cases  of  paralytic  dementia.  The  tremor  of  multiple 
sclerosis,  however,  while  also  jerky  and  ataxic,  is  a  marked  intention 
tremor,  exhibiting  wider  and  wider  excursions  the  greater  the  effort  to 
carry  on  a  voluntary  movement.  The  tremor  of  paresis,  on  the  other 
hand,  shows  no  such  increasing  exaggeration  on  voluntary  efforts  to 
use  the  muscles.  In  sclerosis,  the  head  is  often  involved  in  the  tremor  ; 
in  paresis,  never.  Nystagmus,  so  common  in  sclerosis,  is  almost  never 
observed  in  paresis.  The  dementia  of  sclerosis,  when  present,  is  slight 
and  not  especially  progressive,  and  there  are  no  expansive  or  depressed 
delusional  episodes,  such  as  characterize  paralytic  dementia. 

Focal  brain-lesions  (tumor,  hemorrhage,  softening,  etc.)  with  de- 
mentia and  paralysis  may  simulate  somewhat  certain  types  of  general 
paralysis,  but  the  progressive  character  of  the  latter  disorder,  with  its 
crises  and  psychic  episodes,  should  serve  to  give  the  condition  presented 
definite  outline  and  character. 

Pathological  Anatomy. — It  is  usual  to  describe  the  pathological 
condition  underlying  paralytic  dementia  in  general  terms  as  a  diffuse 
meningo-encephalitis.  The  gross  changes  observed  at  autopsy  are  as 
follows  : 

1.  General  diminution  of  weight  of  the  brain. 

2.  Increased  fluid  in  the  subdural  space  and  in  the  meshes  of  the 
arachnoid  (external  hydrocephalus). 

3.  Pachymeningitis  hemorrhagica  interna,  with  large,  fresh,  or  old 
hematomata  of  the  dura  mater  (in  about  half  of  the  cases). 

4.  Chronic  leptomeningitis  (opacity  and  thickening,  with  adhesion 
of  the  membranes  to  the  cortex). 


742  MENTAL   DISEASES. 

5.  Narrowing  of  the  cortex,  with  gaping  of  the  fissures. 

6.  Distention  of  the  ventricles  with  serum  and  granulated  and  thick- 
ened ependyma  (chronic  internal  hydrocephalus). 

7.  Gray  degeneration  in  the  centrum  ovale,  brain-axis,  in  various 
columns  of  the  spinal  cord,  and  in  some  of  the  spinal  roots  and 
peripheral  nerves. 

The  microscopical  findings  may  be  summarized  briefly  as  follows  : 

1.  Changes  in  the  vascular  walls,  dilatation  of  the  perivascular 
spaces,  wandering  white  and  red  blood-corpuscles. 

2.  Increase  in  number  of  the  astrocytes. 

3.  In  the  ganglion-cells  :  loss  of  the  nucleus  and  nucleolus,  cloudy 
swelling,  shrinking  of  the  protoplasmic  processes. 

4.  Degeneration  and  disappearance  of  the  nerve-fibers  with  myelin- 
sheaths,  in  the  white  matter  and  in  the  cortex,  and  of  the  tangential 
fibers. 

The  whole  cortex  is  more  or  less  affected,  but  often  the  changes  are 
more  marked  in  one  area  than  in  another.  It  is  usual  to  find  the 
frontal  lobes  especially  implicated. 

Treatment. — In  the  majority  of  cases  of  general  paresis  commit- 
ment to  an  asylum  is  necessary,  owing  to  the  dangers  arising  from  the 
patient's  excesses.  He  may  squander  his  property  or  scandalize  his 
family  by  his  immoral  or  criminal  acts.  It  is  true  that  cases  which 
present  merely  the  dual  symptomatology  of  increasing  physical  debility 
with  progressive  mental  enfeeblement  may  be,  and  often  are,  treated 
at  home.  But,  on  the  whole,  it  is  better  to  act  promptly  in  placing  the 
patient  in  a  place  of  safety. 

The  disease  being  inevitably  fatal,  there  is  little  to  be  advised  in  the 
way  of  medication,  save  symptomatic  treatment.  It  is  quite  proper, 
in  cases  with  a  history  of  syphilis,  to  try  energetic  antisyphilitic  meas- 
ures— mercurial  inunctions  and  large  doses  of  iodid.  If,  by  any  pos- 
sibility, there  has  been  any  confusion  of  the  malady  with  cerebral 
syphilis,  this  will  at  least  serve  to  remove  any  doubt.  The  opium  treat- 
ment is  of  value  in  the  periods  of  depression,  and  hyoscin,  hyoscyamin, 
or  duboisin  (gr.  yiro  ^°  Sr-  to)?  hypodermatically,  in  the  periods  of  mani- 
acal excitement.  Where  epileptiform  seizures  are  frequent  the  bromids 
are  indicated,  and  in  status  epilepticus  chloral  and  starch-water  per 
rectum  (gr.  xv  to  5J  of  starch  water).  Chloral  combined  with  morphin 
is  to  be  recommended  in  phases  marked  by  hallucinatory  excitement. 

Little  or  nothing  is  to  be  expected  from  the  many  measures  advo- 
cated by  various  authors  :  setons  and  vesicants  to  the  nape  of  the  neck, 
painting  the  neck  with  iodin,  hydrotherapy,  physostigmin,  ergo  tin,  and 
trepanation. 

Trephining  has  been  resorted  to  a  number  of  times  in  the  past  six 
or  eight  years,  but  seems  to  have  been  abandoned  as  useless.  The 
theory  that  led  to  its  use  was  that  there  might  be  increased  intracranial 
pressure,  but  this  theory  has  been  discarded  for  want  of  evidence. 

When  dysphagia  is  present,  the  patient  may  require  feeding  with 
the  tube.  In  the  terminal  period  of  the  disorder  catheterization  and 
careful  efforts  at  preventing  bed-sores  are  required. 


PARANOIA.  7  13 


CHAPTER   XII. 
PARANOIA. 

Synonyms. — Chronic    delusional    insanity ;     Progressive     systematized     insanity  ; 
Primare  Verriicktheit ;  old  term,  "Monomania." 

Definition. — Paranoia  may  be  defined  as  a  progressive  psychosis 
founded  on  a  hereditary  basis,  characterized  by  an  early  hypochon- 
driacal stage,  followed  by  a  stage  of  systematization  of  delusions  of 
persecution  which  are  later  transformed  into  systematized  delusions 
of  grandeur.  Though  hallucinations,  especially  of  hearing,  are  often 
present,  the  cardinal  symptom  is  the  elaborate  system  of  fixed  delu- 
sions. 

The  hypochondriacal  stage  is  called  by  Regis  "  the  period  of  analytic 
concentration  "  ;  the  second  stage,  "  the  period  of  delusive  explication  "  ; 
the  final  stage,  "  the  period  of  transformation  of  personality." 

Varieties  of  Paranoia. — There  is  one  typical  form  of  paranoia 
to  which  the  main  portion  of  this  chapter  will  be  devoted,  because  it  is 
the  type  which  will  be  most  readily  recognized  by  the  student  and 
general  practitioner.  But  there  are  incomplete  or  immature  forms  and 
atypical  variations,  which  the  special  student  of  morbid  psychology 
learns  in  the  course  of  time  to  distinguish.  Thus,  many  of  those 
eccentric  or  queer  individuals  whom  we  call  "  cranks  "  are  rudimentary 
or  undeveloped  cases  of  paranoia.  Some  idea  of  the  varieties  of  para- 
noia noted  by  authorities  may  be  gathered  from  the  attempts  at  classifi- 
cation by  different  writers.  For  instance,  French  and  Italian  authors 
are  inclined  to  divide  paranoia  into  two  great  groups — viz.,  (1)  degenera- 
tive, with  original  and  late  subvarieties,  according  to  the  period  of 
life  at  which  the  insanity  develops  ;  (2)  psychoneurotic,  with  primary 
and  secondary  subvarieties,  according  to  whether  it  develops  primarily 
or  secondarily  to  another  insanity. 

Ziehen  classifies  paranoia  into  two  great  groups,  according  to  the 
predominance  of  either  delusions  or  hallucinations — where  hallucina- 
tions are  the  most  prominent  symptom,  he  terms  the  psychosis  paranoia 
hallucinatoria ;  where  delusions  are  preeminent,  he  denominates  it  para- 
noia simplex.  Either  form  may  be  acute  or  chronic.  Hence  he  makes 
four  chief  types  :  (1)  Paranoia  hallucinatoria  acuta  ;  (2)  Paranoia  hal- 
lucinatoria chronica ;  (3)  Paranoia  simplex  acuta ;  (4)  Paranoia  sim- 
plex chronica. 

This  last  form  is  the  name  given  by  Ziehen  to  the  complete  typical 
form  of  paranoia  which  is  described  in  this  chapter,  and  which  he 
describes  as  having  four  stages  (prodromal,  persecutory,  expansive,  and 
pseudodemented).  Ziehen  also  specifies  several  varieties  of  acute  hal- 
lucinatory paranoia — viz.,  the  fleeting-idea  form,  the  stuporous,  the 
incoherent,  the  exalted,  and  the  depressive  forms. 

Krafft-Ebing  makes  two  great  divisions — original  paranoia,  appear- 


744  MENTAL  DISEASES. 

ing  in  early  childhood  or  before  puberty,  and  acquired  (tardive)  paranoia, 
appearing  between  the  ages  of  puberty  and  sixty  years.  The  latter 
class  he  subdivides  as  follows  : 

(A)  Paranoia  persecutoria  :  (1)  the  typical  form  ;  (2)  subtype 
(paranoia  sexualis) ;  (3)  paranoia  querulans. 

(B)  Paranoia  expansiva  :  (1)  paranoia  inventoria  and  reformatoria  ; 
(2)  paranoia  religiosa  ;  (3)  paranoia  erotica. 

Etiology. — Heredity  is  a  more  important  etiological  factor  in 
paranoia  than  in  any  other  form  of  insanity.  Krafft-Ebing  states  that 
he  has  never  seen  a  case  without  hereditary  taint.  Tanzi  and  Riva  found 
in  their  cases  of  paranoia  77  per  cent,  of  heredity  and  9.5  per  cent,  of 
infantile  cerebral  disorders,  while  in  the  remaining  14  per  cent,  hered- 
itary factors  could  not  be  ascertained,  but  were  not,  of  course,  ex- 
cluded. It  is  more  common  in  females  than  in  males.  It  affects  by 
preference  individuals  who  are  even  from  childhood  peculiar,  morbid, 
shy,  irritable,  mistrustful,  and  misanthropic.  It  is  very  common  to 
find,  in  cases  of  paranoia,  some  of  the  various  stigmata  hereditatis 
described  in  the  chapter  on  Etiology,  such  as  cranial  or  facial  asymmetry, 
malformations  of  the  ear  or  palate,  etc. 

Symptomatology. — We  will  examine  the  symptoms  of  the  different 
stages  in  the  order  of  their  development.  In  the  prodromal  period,  the 
hypochondriacal  stage  or  period  of  subjective  analysis,  as  it  has  been 
variously  termed,  which  may  have  its  conception  in  early  childhood,  the 
patient  is  morbidly  shy,  peculiar,  eccentric,  avoids  the  companionship 
of  others,  and  is  prone  to  withdraw  himself  into  the  solitude  of  his  own 
thoughts.  The  physiological  commotion  of  puberty  and  adolescence, 
with  its  inflow  into  consciousness  of  innumerable  new  sensations,  its 
flood  of  new  instincts,  powers,  ambitions,  and  ideas,  tends  to  intensify 
the  morbid  proclivities  already  evident.  The  patient  notes  his  own 
peculiarities  of  conduct,  and  begins  to  recognize  the  singularity  of  many 
of  the  somesthetic  sensations  which  come  to  him — sensations  which  at  this 
time  might  well  be  considered  more  or  less  neurasthenic  in  character  : 
paresthesias  of  the  head,  trunk,  viscera,  and  limbs ;  pains  in  various 
parts  of  the  body,  tinnitus  aurium,  sparks  and  dots  before  the  eyes,  and 
the  like.  The  unnaturalness  of  these  sensations  leads  to  his  spending 
much  time  in  contemplation  of  them,  so  that  a  hypochondriacal  com- 
plexion is  given  to  his  thoughts.  To  these  physical  sensibilities  are 
now  added  a  consciousness  of  difficulty  in  the  concentration  of  his 
thoughts ;  a  difficulty  in  the  proper  control  of  the  direction  and  subject 
matter  of  his  thoughts.  He  becomes  extremely  introspective,  and,  the 
more  he  studies  the  somesthetic  sensations  brought  to  his  attention,  the 
more  he  contemplates  the  phenomena  of  the  uncontrollability  of  his 
thoughts,  of  their  rising  unbidden  from  his  subliminal  consciousness, 
of  the  unrestrained  constellation  of  his  presentations,  the  more  is  he 
inclined  to  search  for  some  cause  of  his  morbid  condition.  At  first, 
like  an  ordinary  hypochondriac,  he  investigates  himself  to  find  a  solu- 
tion of  the  problem,  and,  failing  in  that,  he  extends  the  region  of  his 
observation  to  his  environment,  seeking  there  the  reason  of  his  strange 
feelings,  general  disquietude,  and  morbid  stream  of  thought.     He  be- 


PARANOIA.  745 

■comes  wholly  preoccupied  with  himself.  He  can  not  employ  himself, 
either  physically  or  mentally,  as  he  should.  He  fails  in  his  duties — 
in  everything  he  undertakes.  People  seem  strange  to  him  in  their 
conduct  and  in  what  they  say.  He  grows  suspicious  and  distrustful  of 
everything  and  everybody.  What  is  done  and  said  by  others  appears 
to  have  some  significant  relation  to  himself*.  People  niter  in  their  con- 
duct toward  him,  look  at  him  curiously,  smile  sarcastically  when  la- 
passes,  wink  at  or  make  signs  to  one  another  when  he  is  near  ;  make 
observations  among  themselves  which,  overheard  by  him,  are  construed 
as  having  a  double  meaning,  as  being  derogatory  to  him,  reflecting  on 
his  character.  The  more  he  studies  the  extraordinary  condition  of 
affairs,  the  more  gloomy,  solitary,  and  self-absorbed  he  becomes. 
Naturally,  the  growing  alteration  in  himself  really  does  provoke  the 
notice  of  others — a  fact  which  tends  to  intensify  his  ever-increasing 
suspiciousness  of  concealed  animosity  among  those  with  whom  he  comes 
in  contact.  Many  things  in  his  past  life  rise  up  in  his  memory  to  find 
a  new  interpretation  in  the  light  of  his  present  general  distrust.  His 
physical  sensations  have  become  more  marked,  have  taken  on  a  new 
character,  have  altered  from  paresthesias  to  illusions,  and  even  hallucina- 
tions, of  general  or  special  sensibility.  He  feels  peculiar  general  sensa- 
tions, shooting  pains,  sudden  prickings  in  his  skin.  Unusual  and 
unpleasant  odors  or  tastes  harass  him.  Extraordinary  sensations  flow 
into  consciousness  from  his  genital  organs.  Much  more  serious  and 
remarkable,  however,  are  the  peculiar  changes  in  his  auditory  percep- 
tions. At  first  these  are  usually  confused  noises,  or  roaring  and 
tinkling  sounds,  with  the  gradual  perversion  of  sounds  and  words 
heard  into  illusions  colored  by  the  suspicious  contents  of  the  patient's 
consciousness ;  later,  actual  hallucinations  of  hearing,  which  become  a 
fixed  and  permanent  feature  of  his  malady. 

The  patient  now  enters  into  the  second  or  persecutory  period  of 
paranoia,  the  period  of  delusional  explication  of  his  troubles.  He  has 
arrived  at  what  he  conceives  to  be  a  logical  result  of  his  reasonings,  a 
rational  explanation  of  the  distress  and  affliction  he  has  undergone. 
Everything  he  has  suffered  has  been  clue  to  the  machinations  of  un- 
known enemies.  The  delusions  of  persecution  are  at  first  somewhat  con- 
fused in  character.  No  particular  individual  or  group  of  individuals  is 
thus  far  responsible  for  the  inflictions.  It  is  simply  some  unknown 
persons  who  take  pains  to  manifest  ill-will  or  malevolence  toward  him. 
"  They  "  talk  against  him,  call  him  names,  attempt  to  poison  him  with 
gases  or  by  tampering  with  his  food,  and  try  to  injure  him  with  electric 
shocks  or  by  throwing  corrosive  substances  at  him.  Since  wherever  the 
patient  may  be,  wherever  he  may  go,  the  voices,  shocks,  poisons,  etc., 
seem  to  pursue  him,  he  comes  to  think  that  no  single  person  could 
manage  so  vast  a  conspiracy.  It  must  be  some  large  aggregation  of 
persons  who  are  concerned  in  the  effort  to  humiliate,  cripple,  or  destroy 
him ;  an  aggregation  bound  together  by  ties  of  secrecy,  and  able  to  per- 
meate all  classes  of  society.  What  could  such  body  be  but  a  secret 
society,  an  order  of  Masons  or  Odd  Fellows  ;  some  religious  or  political 
brotherhood — the  Jesuits,  Catholics,  Protestants,  anarchists,  or  police. 


746 


MENTAL  DISEASES. 


Perhaps  some  one  individual  is  at  the  head  of  the  band  of  plotters,  some 
arch-conspirator,  but  the  work  is  done  by  innumerable  aides,  who 
employ  all  manner  of  means  and  apparatus  to  accomplish  his  ruin. 
This  system  of  persecutory  ideas  is  built  up  in  the  most  elaborate  way, 
and  the  more  educated  the  individual  suffering  from  paranoia,  the  more 
wonderful  the  organization  and  adjustment  of  the  various  parts  of  the 
delusional  system.  The  persecutory  delusions  of  other  forms  of  psy- 
choses, such  as  toxic  insanity,  senile  dementia,  and  melancholia,  may 
have  a  certain  interest  and  fixity,  but  those  of  the  paranoiac  are  woven 
together  like  a  romance.  The  relation  of  the  former  to  the  latter  is  that 
of  the  brief  sketch  to  the  serial  novel.  The  telephone,  the  phonograph, 
telepathy,   hypnotism,  and  other  and  more  mysterious  apparatus   and 

phenomena  are  brought  into  service 
by  the  relentless  league.  I  do  not 
know  the  origin  of  Du  Maurier's 
conception  of  his  novel,  "  Peter 
Ibbetsen,"  but  I  suspect  that  many 
of  its  unique  features,  especially 
that  of  "  dreaming  true,"  were  sug- 
gested by  conversations  with  some 
well-educated  paranoiac  in  a  lunatic 
asylum. 

Many  patients  seek  in  a  most 
elaborate  way  to  explain  one  pecu- 
liarity of  their  auditory  hallucina- 
tions— viz.,  the  fact  that  their 
thoughts  are  read  off  by  the  voice 
or  voices  simultaneously  with  the 
appearance  of  the  thoughts  in  con- 
sciousness. This  adds  naturally  a 
new  terror  to  the  persecution,  for 
the  ability  of  the  conspirators  to 
read  off  and  taunt  the  patient  with 
his  own  most  secret  thoughts  is 
a  particularly  refined  species  of 
deviltry,  as  well  as  evidence  of  the 
extraordinary  psychological  power 
of  his  tormentors.  The  voice  which  speaks  his  thoughts,  or  answers 
his  thoughts  before  he  can  himself  utter  them,  may  be  referred  to  the 
external  world  or  to  some  part  of  his  own  body.  This  phenomenon 
has  been  variously  termed  echoing  of  the  thoughts,  motor  representation 
of  articulation,  and  verbal  psychomotor  hallucination.  It  depends  upon 
the  close  relation  existing  from  earliest  infancy  between  the  auditory 
word-center  and  the  motor  speech-center.  Any  irritation  of  this  audi- 
tory area  is  immediately,  synchronously,  irradiated  to  the  motor  speech- 
center.  However  slight  this  stimulation  of  the  speech-muscles,  recur- 
rent sensations  of  movement  in  them  are  carried  back  to  the  brain, 
giving  rise  to  the  hallucinations  of  internal  hearing. 

The  patient  is  driven  by  his  delusions   to  make  complaints  to  the 


Fig.  280. — Young  paranoiac  with  homicidal 
tendencies  at  period  of  passing  from  persecutory 
into  grandiose  stage  (Dr.  Atwood). 


PARANOIA. 


747 


police,  to  judges,  or  to  the  governor  of  the  State,  the  President,  or  other 
government  or  judicial  authorities.  Not  infrequently  he  attempts,  him- 
self, to  wreak  vengeance  upon  one  or  more  of  his  imaginary  enemies. 
Attempts  at  homicide  are,  therefore,  common  in  these  eases.  The 
writer  had  in  his  charge  at  the  Poughkeepsie  Asylum,  for  sonic  years, 
Ernest  Duborgue,  a  persecutory  paranoiac,  who,  many  years  ago,  ran 
through  Fourteenth  Street,  New  York,  stabbing  women  right  and  left 
with  a  pair  of  compasses.  More  often  they  seek  to  escape  from  their 
enemies  by  constant  change  of  residence. 

The  third  stage,  the  expansive  period,  or  the  period  of  transforma- 
tion of  personality,  is  often  induced  by  the  patient's  attempt  at  a  logical 
explanation  of  the  cause  of  the  persecution.  Since  he  has  so  many 
enemies,  and  every  man's  hand  is  against  him,  it  must  be  due  to  his 
importance.  He  either  resembles  some  distinguished  personage  or  he 
is  of  royal  or  god-like  descent.  The 
transformation  may  be  suddenly  induced 
by  a  hallucination  revealing  to  him  his 
high  estate.  The  contents  of  these 
delusions  of  grandeur  may  be  religious, 
political,  erotic,  jealous,  and  so  on. 
For  instance,  the  delusion  of  being 
a  prophet  or  a  second  Messiah  is 
very  common  (paranoia  religiosa).  The 
delusion  of  being  a  great  discoverer 
or  inventor  is  frequently  met  with 
(paranoia  inventoria).  Another  com- 
mon delusion  is  that  of  being  a  great 
social  reformer  (paranoia  reformatoria). 
A  peculiar  form  is  paranoia  erotica,  in 
which  a  person  imagines  him-  or  herself 
to  be  beloved  by  some  one  of  superior 
station.  It  is  a  romantic,  platonic  love 
in  which  the  patient  indulges.  He 
has  communications  with  the  object  of 
his  delusions,  imaginary  conversations, 

through  the  medium  of  hallucinations.  A  good  example  of  this  form  was 
that  of  Dougherty,  who  followed  Mary  Anderson  all  over  the  country, 
and  was  finally  sent  to  an  asylum  because  of  his  threats  to  kill  any  one 
who  interfered  with  his  attempts  to  gain  a  personal  interview  with  the 
famous  actress.  Measurements  which  I  made  of  his  head  showed  a 
pathological  excess  in  the  height  of  the  skull. x  After  his  commitment 
to  an  asylum  he  shot  one  of  the  physicians  who  had  him  in  charge. 
Another  interesting  variety  of  paranoia  is  that  observed  in  the  litiga- 
tionists  (paranoia  querulans),  who  occasionally  distinguish  themselves  by 
their  lifelong  involvement  in  legal  processes  (due  to  an  overwhelming 
egotism,  which  leads  to  a  continual  zealous  effort  to  set  themselves  right, 
despite  the  advice  of  friends,  and  the  wasting  of  their  property,  after  the 

1  "Familiar  Forms  of  Nervous  Disease,"  by  M.  Allen  Starr,  New  York,   1890. 
Article  on  "Paranoia,"  by  F.  Peterson,  page  299. 


Fig.  281.— Erotic  paranoia.  "  Mary  Ander- 
son's lover  "  (see  text). 


748  MENTAL   DISEASES. 

loss  of  some  possibly  trivial  lawsuit).  Pretenders  to  thrones,  self-styled 
kings,  presidents,  princes,  and  so  on,  are  often  noted  among  paranoiacs 
who  have  reached  this  third  stage  of  evolution.  Quite  commonly  per- 
secutory ideas  still  remain  in  the  minds  of  these  patients  in  association 
with  the  delusions  of  grandeur. 

Each  of  these  periods  of  development  may  last  for  several  years, 
the  disorder  may  undergo  arrest  at  any  period,  and  there  may  be  varia- 
tions in  the  degree  of  development  of  any  stage ;  so  that  we  constantly 
meet  with  atypical  forms  of  paranoia.  An  excellent  condition  of 
memory,  judgment,  and  intellect  in  all  other  directions  save  in  those 
related  to  the  single  cluster  of  delusions  may  coexist.  Years  ago  these 
cases  were  designated  as  monomania,  because  of  the  apparent  lucidity 
of  the  patient  outside  of  the  limited  number  of  fixed  ideas.  Many 
paranoiacs  have  distinguished  themselves  in  sacred  and  profane  history, 
and  even  in  literature.  There  have  been  many  of  these  false  prophets 
who  have  come  to  herald  a  new  religion — Mahomet,  Swedenborg, 
Johanna  Southcott,  John  of  Leyden,  John  Thom  of  Canterbury,  and 
Jeanne  d'Arc.  We  have  had  them  even  in  the  United  States  within 
a  few  years — the  healers  exploited  by  the  press.  Among  political  re- 
formers we  had  John  Brown  and  Guiteau.  A  famous  paranoiac  immor- 
talized himself  in  his  autobiography — Benvenuto  Cellini. 

I  have  in  my  possession  a  beautifully  written  manuscript — the 
autobiography  of  a  paranoiac.  He  was  so  dangerously  insane  that  he 
spent  much  of  his  life  in  the  asylum  in  which  he  wrote  this  valua- 
ble work. 1  The  volume,  bound  by  himself,  is  entitled  "  The  Piling 
of  Tophet,"  which  is  significant  of  the  sufferings  he  had  undergone  in 
his  unhappy  life.  I  believe  no  better  idea  of  the  typical  form  of  para- 
noia can  be  obtained  than  by  a  careful  reading  of  the  history  of  this 
case  as  given  by  the  person  himself.  It  is  a  graphic  picture  of  the 
steady  evolution  of  the  malady — a  remarkable  self-dissection  of  the 
soul's  anatomy.  Before  presenting  the  extracts  from  his  autobiography, 
I  shall  make  a  few  transcripts  from  his  asylum  history. 

He  was  thirty  years  of  age  at  the  time  of  admission  ;  single  ;  a  farm- 
laborer  by  occupation.  He  was  not  a  church-member,  had  a  common- 
school  education,  and  was  a  native  of  the  United  States.  Hereditary 
predisposition  was  not  acknowledged.  His  mother,  who  accompanied 
him  to  the  hospital,  stated  that  he  had  always  been  delicate  in  his  physi- 
cal constitution,  and  given  to  despondency.  Since  the  age  of  twenty 
he  had  done  little  or  nothing,  because  of  ill  health.  A  year  previous 
to  his  commitment  to  the  hospital  as  a  lunatic  he  shot  himself  in  the 
forehead  in  an  ineffectual  attempt  at  suicide.  Later,  he  developed  de- 
lusions that  the  people  of  the  village  were  acting  upon  him  by  mag- 
netism, spoke  disparagingly  of  him,  and  were  conspirators  against  his 
peace.  During  the  whole  of  his  sojourn  in  the  hospital  he  had  hallu- 
cinations of  hearing,  and  in  the  earlier  period  of  his  stay  had  delusions 
of  persecution.  Toward  the  end  of  his  seven  years  of  hospital  life  he 
gradually  developed,  in  addition,  delusions  of  grandeur.     Although  he 

1  ' '  Extracts  from  the  Autobiography  of  a  Paranoiac, ' '  edited  by  Frederick  Peter- 
son, "Amer.  Jour,  of  Psychology,"  January,  1889. 


PARANOIA.  749 

had  occasional  lapses  of  self-control,  manifested  by  the  breaking  of 
window-glass  or  the  tearing  of  clothing,  he  was  for  the  greater  portion 
of  the  time  sufficiently  self-possessed  to  restrain  whatever  violent  or 
destructive  inclinations  he  may  have  had,  and  was  permitted  to  go  out 
alone  upon  the  large  grounds  of  the  asylum  whenever  he  wished,  and 
to  wander  about  the  woods  at  will. 

It  was  during  the  last  two  years  of  his  stay  at  the  asylum,  while 
still  the  victim  of  constant  auditory  hallucinations,  and  of  mingled 
delusions  of  persecution,  unseen  agency,  and  grandeur,  that  he  wrote 
the  volume  of  four  hundred  manuscript  pages  with  the  extraordinary 
title  of  "  The  Piling  of  Tophet,"  this  title  being  founded  upon  Isaiah 
xxx,  33.  The  book  itself  is  a  deeper  history  of  his  life  and  mental 
evolution  than  any  but  himself  could  furnish.  It  is  remarkable  for  its 
excellent  literary  style  and  for  its  keen  reasoning  and  psychological 
analysis  of  his  own  disordered  mind.  In  it  he  dissects  his  hallucina- 
tions and  delusions  like  a  skilled  anatomist.  It  is  as  fascinating  as  a 
novel.  Every  page  has  its  value  as  an  index  of  the  condition  of  his 
mind  from  childhood  to  the  last  years  of  his  confinement  in  the  asylum  ; 
and  the  story  is  told  with  a  directness  and  simplicity  that  marks  truth 
upon  every  statement  and  lends  it  such  charm  as  pertains  to  all  wrorks 
which  portray  life  with  the  utmost  fidelity.  In  his  preface  and  intro- 
duction he  makes  a  diagnosis  of  his  own  disease. 

Our  author,  as  has  already  been  stated,  was  not  a  church-member, 
and  in  his  book  he  describes  his  early  religious  life  and  his  subsequent 
beliefs  as  they  developed.  His  father  was  a  Universalist  and  his 
mother  a  non-professor  of  religion,  although  she  did  attend  the  Meth- 
odist church.  During  his  boyhood  he  attended  the  Sunday-school 
regularly,  and  at  one  time  the  Episcopal  church ;  but  his  attendance 
upon  divine  service  ceased  in  early  youth.  Both  parents  were  honest, 
conscientious,  and  highly  respected  in  the  community.  They  were  first 
cousins.  The  mother  was  healthy  in  mind  and  body,  but  the  father  is 
reported  to  have  been  exceedingly  eccentric,  possibly  insane.  From 
what  I  subsequently  learned  regarding  him,  he  also  was  something  of  a 
paranoiac.  They  strove  to  bring  up  their  children  carefully  and  to 
educate  them  as  well  as  possible. 

His  father  died  when  the  patient  was  twelve  years  of  age.  Up  to 
the  age  of  thirteen  he  attended  a  country  school  both  winter  and  summer, 
but  after  that  his  farm-work  permitted  him  only  winter  schooling.  Still, 
he  evidently  had  unusual  talents  and  aptitudes,  and  we  find  him  later 
studying  by  himself,  in  the  original,  many  of  the  classic  Latin  authors ; 
and  among  his  favorite  companions  were  the  works  of  Boethius,  Lucre- 
tius, Josephus,  and  the  Bible.  His  literary  style  and  modes  of  thought 
are  in  themselves  an  evidence  of  more  than  ordinary  attainments  in 
rhetoric,  philosophy,  and  logic. 

The  matter  of  heredity  in  his  case  was  not  sifted  thoroughly  upon 
his  admission  to  the  asylum,  nor  have  I  since  been  able  to  gather  much 
material  relative  to  this  factor  in  his  evolution.  But  one  important 
element  of  this  nature  is  described  in  his  book — an  element  not  only 
hereditary  in  its  character,  but  for  a  long  time  part  of  his  environment, 


750  MENTAL  DISEASES. 

and  undoubtedly  an  influence  modifying  his  mental  condition  both 
before  and  after  his  birth.  I  allude  to  a  great-uncle,  a  brother  of  his 
grandmother  on  his  mother's  side,  who  was  himself  a  paranoiac,  and  who 
lived  upon  the  farm  in  intimate  companionship  with  our  patient  until 
the  latter  was  twenty-three  years  old. 

As  we  read  on  we  see,  from  the  author's  account  of  himself,  how 
heredity  and  environment  gradually  molded  his  physical  and  mental 
characters.  A  shy,  timid,  delicate  child  ;  clever  intellectually  ;  given  to 
oddities  of  speech  and  conduct ;  inclined  to  solitary  musing,  rarely  shar- 
ing the  sports  or  games  of  other  boys — in  him  were  slowly  evolved 
marked  eccentricity  of  demeanor,  a  disposition  to  shun  his  fellows,  a 
misinterpretation  of  their  looks  and  actions  as  regarded  himself,  a  mor- 
bid egotism,  a  consciousness  of  a  gulf  between  himself  and  ordinary 
men,  with  deep  depression,  outbursts  of  passion,  an  inclination  to 
homicide  restrained  but  feebly  by  his  weakened  will,  and  delusions  of 
persecution.  No  doubt  the  derogatory  remarks  he  fancied  expressed 
about  him  in  the  stores  were  the  first  harbingers  of  auditory  hallucina- 
tions. Later,  he  had  murder  in  his  thoughts,  through  the  morbid  hu- 
miliation he  felt  at  the  imaginary  insults  from  others.  No  doubt,  as 
his  conduct  grew  more  and  more  strange,  he  did  attract  attention  among 
his  fellow-men,  and  this,  unfortunately,  would  but  feed  the  flame  of  his 
pathological  self-consciousness. 

We  follow  his  history  from  infancy  through  childhood  and  youth  to 
manhood,  and  observe  how,  slowly  but  surely,  the  hereditary  seed  sown 
in  degenerative  soil  took  root  and  flourished.  His  peculiar  auditory 
acuteness,  with  his  morbid  shyness,  soon  gave  rise  to  illusions  of  hear- 
ing, and  these  again  were  transformed  into  hallucinations,  as  is  evident 
if  the  thread  of  the  narrative  is  carefully  followed.  The  curious  foun- 
dation of  his  hallucinations  he  well  illustrates  and  understands.  An 
idea  arises  in  his  own  mind  of  what  people  would  say  in  discussing 
him,  and  immediately  consciousness  in  the  auditory  area  projects  the 
idea  in  spoken  words  into  the  environment.  He  noted  this  peculiarity 
of  his  own  thoughts  being  repeated  to  him  by  the  voices  about  him,  yet 
he  could  not  correct  the  delusions  to  which  they  gave  origin,  but  inter- 
preted the  matter  with  the  reason  and  judgment  of  an  insane  mind. 
He  naturally  had  the  delusion,  founded  upon  his  hallucinations,  that 
people  were  persecuting  him,  but  upon  this  now  grew  another  delusion. 
He  began  to  believe  that  they  could  read  and  repeat  his  thoughts  ;  that 
there  was  some  magnetic  means  by  which  his  tormentors  could  draw  off 
his  thoughts  ;  that  other  wills  could  act  upon  his  body,  dominating  his 
own  will  and  causing  him  to  do  things  he  had  no  desire  or  intention  of 
doing. 

It  was  about  this  time  that  he  was  removed  to  the  asylum.  Several 
chapters  of  his  book  are  devoted  to  a  description  of  his  life  there,  his 
religious  beliefs,  illusions,  and  hallucinations.  A  short  time  previous 
to  his  departure  for  the  asylum  he  began  to  read  much  in  the  Bible, 
and,  as  he  says,  noted  passages  which  seemed  to  have  a  special  bearing 
as  regarded  himself.  There  were  several  coincidences  of  this  kind,  and 
he  looked  upon  them  at  first  as  merely  coincidences,  but  in  time  the 


PARANOIA.  751 

resemblance  became  so  strongly  marked,  to  his  disordered  intelligence, 
that  he  came  to  look  upon  whole  chapters  of  the  Bible  as  referring  to 
himself.  From  this  the  step  was  not  a  great  one  to  the  delusion  of 
being  a  prophet.  In  reading  we  find  that  our  author  had  several  in- 
centives for  writing  this  book.  It  contains  the  autobiography  of  a  new 
prophet,  as  well  as  the  revelation  of  a  new  religion.  From  his  stand- 
point, as  a  man  in  whose  destiny  are  wrapped  up  the  destinies  of  the 
world,  he  tells  posterity  of  the  tortures  and  trials  lie  has  passed  through 
as  an  atonement  for  the  sins  of  the  earth  ;  how  he  was  mocked  and 
scoffed  at,  his  brain  acted  upon  by  magnetic  agency,  and  himself  im- 
prisoned in  a  lunatic  asylum  for  years.  Hence  the  "title  of  his  book, 
"  The  Piling  of  Tophet."  But  behind  this  insane  egotism  there  shines 
at  times  some  faint  glimmer  of  the  truth,  so  that  he  frequently  speaks  of 
himself  in  the  terms  used  by  his  fellows,  as  insane,  a  lunatic,  a  mono- 
maniac, as  having  hallucinations ;  and  he  thinks  the  opinions  of  his 
friends,  relatives,  and  physicians  of  sufficient  worth  to  merit  considerable 
argument  in  his  book.  He  knows  what  insanity  is  ;  he  recognizes  it  in 
his  asylum  associates.  He  could  at  times  "  see  the  man  he  ought  to 
have  become  rising  up  like  a  shadowy  phantom  in  judgment  on  the 
wreck  he  really  was."  But  this  occasional  consciousness  of  their  dis- 
ordered mental  condition  is  by  no  means  infrequent  in  the  insane. 

Shortly  after  writing  his  autobiography  he  was  removed  to  a  county 
asylum,  where  he  remained,  without  change  in  his  mental  condition,  for 
several  years,  when  his  friends  took  him  out  to  live  with  them.  He  died 
a  religious  paranoiac  in  1886.  He  did  not  become  completely  imbecile, 
as  such  cases  often  do  ;  nor  did  he  write  any  further  articles,  so  far  as  I 
am  aware.  Doubtless  the  indifference  with  which  the  world  received 
the  propagandism  of  the  new  prophet  caused  his  philosophical  with- 
drawal from  active  warfare  in  the  fields  of  reform  and  theology. 

In  the  preface  he  defines  the  scope  of  the  book  as  follows  : 

"This  work  is  given  to  the  public  as  a  lunatic's  defense  of  his  posi- 
tion. Every  effort  I  have  made  hitherto  to  come  to  an  understanding 
with  my  fellow-men,  on  things  which  I  see  to  proceed  from  them,  and 
which  give  my  life  its  whole  shape,  has  drawn  out  nothing  more  than 
blank  denials  of  all  knowledge  of  the  things  I  spoke  of.  Now,  it  is  im- 
possible for  me  to  reduce  my  thoughts  to  the  bounds  which  others  have 
been  willing  to  concede.  The  object  of  this  little  autobiography  is  to 
show  the  form  and  consistency  of  the  thought  that  is  in  my  mind. 

"  I  present  my  evidence  to  the  tribunals  of  last  resort,  the  public  and 
the  press,  and  ask  them  to  try  the  case  and  render  their  verdict.  Have 
I  a  right  to  my  thought,  or  have  I  not  ?  If  not,  where  am  I  deceived  ? 
If  I  have,  why  is  not  mine  the  true  thought  for  all  men  ?  ' ' 

A  paragraph  from  the  introduction  further  reveals  the  object  of  his 
confessions  : 

' '  A  person  is  supposed  to  have  a  reason  for  what  he  does,  and  I 
might  consider  it  incumbent  upon  me  to  tell  the  motives  which  actuate 
me  in  thus  entering  upon  the  work  of  the  scribe  under  circumstances  so 
peculiar.     Is  there  anything  I  have  to  tell  that  might  not  as  well  and 


752  MENTAL   DISEASES. 

more  safely  be  left  untold  ?  It  is  a  question  which  I  do  not  have  to- 
consider  and  decide  to-day,  for  I  have  been  long  inspired  with  the  con- 
viction, the  consciousness,  that  I  have  something  to  tell  that  it  would  be 
worth  the  world's  while  to  hear." 

In  another  introductory  paragraph  he  makes  an  excellent  diagnosis 
of  his  mental  infirmity.     Addressing  his  reader,  he  says  : 

' '  I  did  not  tell  you  that  I  am  a  patient  in  an  asylum.  I  am  to  take 
it  for  granted  at  the  outset  that  my  prospective  reader  knows  nothing  of 
my  character,  condition,  or  circumstances  beyond  what  I  tell  him.  I 
am  here  as  an  insane  patient.  I  have  been  here  over  five  years.  .  .  . 
Being  an  insane  man,  it  will  be  nothing  unexpected  that  I  should,  in 
giving  these  reports  of  my  fortunes,  narrate  incidents  and  particulars 
partaking  more  or  less  of  the  marvelous  or  preternatural.  I  am  not 
only  a  lunatic,  but  one  of  the  class  of  lunatics  having  a  controversy  with 
the  world  in  general;  in  other  words,  possessed  with  a  monomania,  or 
crazy  one-sidedly  or  on  a  single  subject." 

In  the  hospital  record  presented  above,  nothing  is  adduced  as  to- 
heredity  in  this  case,  and  but  little  stated  concerning  his  mental  condi- 
tion in  early  youth.  These  deficiencies  are,  to  a  great  extent,  supplied 
in  the  autobiography.  I  shall  permit  our  author  first  to  describe  his 
appearance  in  this  world,  in  a  cyanotic  condition,  and  the  characteristics 
of  his  childhood  and  early  youth,  and  subsequently  the  hereditary 
influence  in  his  destiny  : 

"It  is  said  that  I  was  entirely  black  when  I  was  ushered  into  the 
world,  and  that  for  I  forget  how  long  a  period  of  time  I  did  nothing 
but  give  vent  to  heart-saddening  wails.  Was  I  lamenting  the  gift  of 
light,  on  this  morning  of  what  was  to  become  a  woe-burdened  existence  ? 

' '  I  was  a  weakly  infant.  I  came  near  dying  of  the  whooping-cough, 
and  it  was  always  asserted,  by  those  who  knew,  that  I  owed  my  life  to 
the  untiring  exertions  of  a  poor  woman  who  lived  a  neighbor,  who 
busied  herself  all  night  with  me,  dipping  me  at  intervals  into  a  tub  of 
warm  water.     My  half-sister  had  it  at  the  same  time  and  died. 

' '  It  will  be  of  use  to  give  an  idea  of  my  nature  and  disposition  in 
my  tender  years.  I  was  always  a  shy,  retiring  child;  not  disposed  to 
make  free  with  strangers;  not  much  given  to  prattle — in  fact,  one  of  the 
sad  and  silent  sort  from  the  first.  I  can  remember  some  peculiar  sensa- 
tions which  used  to  weigh  on  my  mind,  which  go  to  show  that  the 
foundation  of  my  mind-life  was  but  imperfect  from  the  first.  I  used  to 
be  troubled  with  very  strange  feelings  when  I  was  waking  out  of  sleep, 
especially  if  I  had  been  taking  a  nap  in  the  day-time.  It  used  to  seem 
to  me  that  I  was  floating  in  the  air,  and  I  often  thought  to  myself  : 
'  Why,  how  queer  I  have  been  feeling! '  It  was  as  if  I  filled  the  whole 
room,  way  up  to  the  ceiling.  I  was  told  by  others  that  I  sometimes 
raised  myself  up  in  bed  after  getting  to  sleep  and  made  an  outcry,  '  Oh, 
don't!  Oh,  don't! '  seeming  to  be  in  great  distress;  but  the  strange  part 
of  it  is  that  I  could  remember  nothing  about  it.  I  do  not  think  that  I 
ever  remembered  even  their  waking  me,  or  finding  them  at  my  bedside. 
I  only  had  their  word  for  it  next  day. 

"  As  far  as  I  can  go  back,  I  remember  having  at  times,  but  not  fre- 


I1  Mi  AN  01  A.  753 

quently,  impressions  which  must  be  identical  with  what   I  have  lately 

heard  others  speak  of  as  'double  memory.'  The  feeling  would  all  at 
once  creep  over  me  that  the  very  thing  I  was  present  with,  my  ideas  and 
perceptions  at  that  time,  had  happened  to  ni<-  once  before  in  just  the 
same  sequence  and  arrangement.  I  have  heard  this  explained  as  due 
to  a  lack  of  simultaneity  in  the  action  of  the  two  lobes  of  the  brain,  the 
tardy  one  remembering  what  had  already  passed  through  the  other. 
My  own  theory  was  different,  leaving  the  organ  acting  out  of  con- 
sideration. I  only  went  so  far  as  to  look  at  it  as  a  mistaken  quality 
in  the  perception — an  erroneous  attaching  of  the  nature  of  the  act  of 
remembering  to  what  Avas  really  the  act  of  thinking  in  the  present. 

"  I  was  very  early  in  life  an  observer  of  my  own  mental  peculiarities, 
to  a  degree  which  I  think  must  be  a  very  rare  exception.  I  often  used 
to  be  sensible  of  an  unsatisfactoriness  in  my  consciousness  of  what  sur- 
rounded me.  I  vised  to  ask  myself,  '  Why  is  it  that  while  I  see  and 
hear  and  feel  everything  perfectly,  it  nevertheless  does  not  seem  real  to 
me  ?  It  is  as  if  I  were  in  danger  of  forgetting  myself  and  the  place 
where  I  am! '  I  often  wondered  even  how  I  kept  the  run  of  things  as 
well  as  I  did.  I  always  found  myself  holding  on  to  the  orderly  and 
proper  connection  of  my  acts,  and  yet  from  my  feelings  I  could  not  have 
answered  for  my  doing  so.  I  can  remember  sitting  at  my  desk  in 
school,  when  a  small  boy,  and  dwelling  with  melancholy  on  this  dim- 
ness in  my  perception  of  existence,  and  wondering  how  it  was  with 
others  in  this  respect.  I  wondered  to  myself  if  life,  as  ordinarily  be- 
stowed, included  this  deficiency. 

' '  I  showed  in  my  tastes  and  behavior  a  harmony  with  the  internal 
composition  of  my  mind.  I  was  never  given  to  the  active  sports  which 
the  common  run  of  boys  take  so  much  delight  in. 

' '  The  simple  fact  is  that  I  had  a  languid  nervous  development,  and 
from  the  necessity  of  my  organization  could  not  have  much  capacity  or 
relish  for  sports  of  agility. 

"  If  I  could  compound  a  boy  of  my  own  I  should  try  to  improve  on 
the  model  I  remember  to  have  exhibited  in  myself. 

"  It  is  not  true  that  I  was  regarded  or  treated  as  strange  or  deficient 
in  my  wits.  Such  an  idea  would  look  misplaced  to  those  who  knew 
me  and  consorted  with  me  in  those  days.  These  differences  are  perhaps 
more  evident  to  myself  than  they  ever  were  to  the  greater  part  of  my 
acquaintances.  I  brooded  on  this  side  of  my  character  at  a  later  period, 
and  I  no  doubt  remain  liable  to  give  greater  prominence  to  disparaging 
traits  than  some  impartial  observers  would  justify  me  in  doing. 

"Asa  general  rule,  my  harmless  and  peaceable  disposition  kept  me 
out  of  squabbles  with  my  schoolmates.  If  I  was  approached  in  an 
aggressive  way,  I  met  it  with  absolute  non-resistance,  which  in  my  case 
had  the  disarming  effect  which  is  attributed  to  it  by  pious  moralists. 

"  If  we  change  the  scene  from  the  playground  to  the  schoolroom,  we 
shall  find  that  I  attained  a  distinction  of  my  own,  apart  from  the 
average,  and  more  to  my  advantage  there.  I  was  always  a  favorite  with 
my  teachers.  I  never  gave  them  any  trouble,  and  took  to  my  studies 
with  a  willing  relish  that  could  not  but  be  pleasing  to  them.  I  learned 
to  read  before  I  went  to  school;  in  fact,  like  an  old  asylum  acquaint- 
ance, Mr.  M.,  inventor  and  infidel  monomaniac,  I  can  almost  say  that 
I  can't  remember  when  I  could  not  read. 

' '  I  was  frequently  singled  out  for  complimentary  remarks  on  my 

48 


754  MENTAL  DISEASES. 

proficiency  in  my  studies.     I  gave  evidence  of  some  talents  of  a  higher 
kind — could  draw,  for  instance,  better  than  any  boy  in  the  school. 

' :  One  of  the  most  marked  weaknesses  of  my  character,  as  a  child, 
was  my  susceptibility  to  being  teased. 

' '  After  having  pondered  some  on  the  traits  of  the  human  animal  in 
this  particular,  I  have  come  to  the  conclusion  that  there  is  no  further 
explanation  needed  than  that  the  impression  made  on  the  teaser  by  the 
teasable  is  such  as  to  naturally  prompt  the  acts  constituting  the  teasing, 
as  the  sense  of  burning  makes  us  shrink,  and  an  aroma  suggestive  of  a 
fine  flavor  tempts  us  to  bite.  I  feel  convinced  that  the  liability  to  be 
teased  rests  on  a  principle  that  has  a  mighty  influence  in  the  motions  of 
the  soul  of  humanity. 

' '  My  misdeeds,  as  a  child,  were  rarely  prompted  by  a  love  of 
mischief  or  the  result  of  headlong  thoughtlessness. 

' '  I  had  a  well-defined  idea  of  the  nature  of  sin,  and  I  used  fre- 
quently at  night  to  recall  the  events  of  the  day,  and  reflect  on  instances 
in  which  I  had  transgressed  and  given  way  to  ill-humor,  and  form  reso- 
lutions to  try  and  do  better.  From  some  of  the  most  flagrant  of  the 
sins  and  improprieties  to  which  small  and  larger  boys  are  prone  I  was 
entirely  free. 

' '  My  early  training  can  not  be  said  to  have  been  a  predominantly 
religious  one.  My  mind  was  neither  imbued  with  ineradicable  preju- 
dices nor  prepared  for  reaction  to  the  other  extreme  by  excessively  rigid 
sectarian  drilling  and  formalism. 

' '  I  worked  steadily  upon  the  farm,  though  with  moderation,  at 
such  kinds  of  work  as  I  seemed  to  be  equal  to.  The  heavier  kinds  of 
work,  such  as  plowing  and  wagoning,  as  also  the  marketing  of  the 
produce,  were  attended  to  by  my  great-uncle. 

"It  is  a  somewhat  delicate  subject  to  manage  to  my  satisfaction 
this  that  I  am  about  to  enter  upon,  but  it  demands  candid  and  impar- 
tial treatment,  because  the  events  that  followed  in  later  years  can  not 
be  rightly  understood  without  it.  It  is  impossible  for  me  to  give  a 
veracious  sketch  of  my  soul-life  during  this  period  without  dwelling 
quite  minutely  on  the  characteristics  of  my  great-uncle.  He  was  a  man 
who  had  roughed  it  a  good  deal  in  the  world,  had  been  at  one  time  in 
his  life  a  live-oaker  in  Florida.  How  his  temper  and  disposition  may 
have  been  at  an  earlier  period  I  can  not  say — I  only  remember  him  as 
a  man  possessed  of  the  belief  that  a  certain  young  man  living  on  an 
adjoining  farm  had  the  power  to  torture  him  at  his  pleasure,  both  by 
bothering  his  brains  and  inflicting  physical  pain;  which  power  he  made 
use  of  to  such  good  effect  that  the  poor  victim  was  almost  constantly 
kept  busy  holding  him  at  bay  by  means  of  cursings  of  the  most  fierce 
and  vigorous  description.  While  at  work  with  the  horses  in  the  fields, 
and  when  driving,  he  would  intermix  his  commands  to  the  animals 
with  savage  execrations  of  the  troubler  of  his  peace.  The  unfortunate 
man  was  troubled,  at  certain  seasons  of  the  year  especially,  with  sore 
feet,  and  at  such  times  his  imprecations  against  the  offender  would 
fairly  rise  to  yells,  and  were  almost  blood-curdling  in  their  intense 
ferocity.  Thus  it  went  on  day  and  night.  He  slept  in  a  small  room  in 
one  of  the  outbuildings,  and  often  he  could  be  heard  at  a  great  distance 
off  shouting  out  threats,  sometimes  throwing  boots  or  boot-jacks  against 
the  boarded  side  of  the  building  where  he  lodged  to  put  in  the  inter- 
jection points. 


PARANOIA.  755 

"  It  may  be  imagined  that  a  boy  of  a  reserved  and  sensitive  disposi- 
tion, as  I  was,  could  not  assimilate  very  well  with  such  a  character  as 
this.  I  was  always  distant  in  my  intercourse  with  him,  and  a  feeling 
of  aversion  for  his  habits  of  savagery  Led  me  to  avoid  coming  in  contact 
with  him  more  than  was  rendered  necessary  by  our  joint  labors  on  the 
farm. 

"As  the  years  passed  on  and  I  continued  to  live  in  the  presence 
of  my  uncle's  fierce  demonstrations  of  hostility  against  the  invisible 
destroyer  of  his  comfort,  my  tolerance  for  his  conduct  insensibly  gave 
way.  I  had  now  reached  the  age  of  eighteen  or  nineteen;  was  a  tall, 
slender  youth,  not  strong  either  in  nerve  or  muscle. 

"The  exhibition  of  his  ruling  passion  called  up  more  and  more 
determined  feelings  of  antagonism  in  my  breast. 

"  Before  I  knew  it  I  had  gone  a  criminal  length  in  my  resentful 
feeling.  I  came  at  last  to  feel  that  a  person  of  such  a  thoroughly 
savage  character  did  not  deserve  more  indulgence  than  a  mad  dog.  My 
position  from  that  time  was  one  of  contingent  murder.  Alas  !  that  I 
should  have  been  content  to  let  such  a  state  of  things  last  a  single  day. 
The  frightful  clanger  of  my  situation  ought  to  have  been  sufficient  to 
spur  me  to  sacrifice  everything  to  escape  from  it.  But  I  was  in  chains, 
the  chains  of  apathy,  impotence,  and  incapacity,  and  I  could  only  stay 
where  I  was  and  fume  against  the  object  of  my  detestation. 

' '  I  must  always  regard  it  as  one  of  the  most  unfortunate  things  in 
my  unfortunate  career  that  I  should  have  been  placed  in  contact  with 
this  much  to  be  commiserated  sufferer  at  such  a  time  of  life.  It  was 
not  the  man  himself  that  I  hated.  When  my  judgment  could  act  with- 
out impediment,  I  saw  that  his  unpleasant  behavior  was  entirely  the 
phenomena  presented  by  his  never-ending  war  against  what  was,  in  his 
eyes,  the  most  wicked  and  cruel  of  persecutions.  I  could  then  pity  him 
and  dismiss  all  rancorous  thoughts. ' ' 

This  antipathy  led  to  a  change  in  the  residence  of  our  author.  He 
felt  that  he  must  be  separated  from  his  uncle,  and,  accordingly,  he  re- 
moved to  a  town  at  some  distance  from  the  farm.  It  is  curious  that 
he  never  speaks  of  his  uncle  as  insane,  and  it  is  probable  that  both  his 
mother  and  himself  and  other  relatives  regarded  his  persecutory  delu- 
sions as  merely  evidence  of  eccentricity.  Soon  after  removing  to  town 
he  had  some  pulmonary  difficulty,  and  he  speaks  at  some  length  of  this 
as  follows  : 

1 '  In  the  depressed  state  of  my  nerves  I  imagined  myself  much  worse 
than  I  really  was,  and,  like  many  others  in  the  same  condition,  I  felt 
as  if  I  was  liable  to  sink  away  and  die  at  any  time.  My  disease  was 
accompanied  with  periodical  accesses  of  fever,  and  in  the  fictitious 
strength  of  excitement  given  by  this  my  mind  seemed  to  gain  an  ab- 
normal activity.  It  was  at  this  time  that  I  first  received  a  revelation  on 
the  mysteries  of  the  human  soul  that  had  an  all-dominant  effect  on 
my  destinies  and  the  turn  of  my  thoughts  ever  after.  ...  I  now 
learned  what  had  always  been  to  me  a  hidden  mystery — what  was  the 
meaning  of  strength  of  will  and  strength  of  intellect.  Before,  I  had  ever 
lived  enshrouded  in  mists  and  clouds.  In  that  transitory  strength  given 
by  the  fever  coursing  through  my  veins,  I  now  saw  the  man  I  ought 
to  have  become  rising  up  like  a  shadowy  phantom  in  judgment  on  the 


756  MENTAL  DISEASES. 

wreck  which  I  really  was  .  .  .  My  agitation  was  so  great  that  my 
mother  and  the  neighbors  seemed  to  fear  that  I  was  going  crazy.  / 
felt  that  I  had  been  crazy  for  a  long  while  and  had  just  recovered  reason. 
It  was  a  fact.  But  I  was  constrained  to  lock  up  my  remorseful  agony 
in  my  own  breast. ' ' 

We  have  seen  that  our  patient  was  throughout  his  early  youth 
morbidly  subjective,  and  his  hypochondriasis  increased  with  years.  He 
had  now  attained  the  age  of  twenty-three  ;  we  shall  let  him  describe  his 
mental  condition  and  habits  of  life  at  this  time.  In  this  description  we 
shall  see  the  gradual  growth  of  persecutory  ideas  upon  a  favorable  soil : 

"My  strength  and  endurance  were  not  sufficient  for  manual  labor, 
and  I  did  not  feel  confidence  enough  in  the  clearness  and  energy  of  my 
mind  to  justify  me  in  making  application  for  any  post  where  head-work 
would  have  been  demanded,  or  for  which  ready  presence  of  mind  or  a 
good  address  would  have  been  required.  But  it  was  the  unpleasantness 
felt  on  contact  with  my  fellow-men  that  operated  more  strongly  than 
anything  else  in  binding  me  down  to  the  course  of  life  to  which  I  de- 
voted myself.     I  felt  my  deficiencies  most  keenly  every  time  I  met  a 

human  being  face  to  face I  could  not  do  otherwise  than 

shun  what  was  so  galling  to  my  sensibility,  while  appearing  to  conduce 

to  no  desirable  end But  I  am  going  to  show  that  I  still 

remained  exposed  to  very  great  dangers,  and  it  is  as  true  as  it  was 
before  that  I  shunned  the  only  means  of  averting  the  calamities  threat- 
ening me,  no  doubt  of  necessity  at  this  stage,  and  in  obedience  to  the 
eternal  decree  that  every  tree  shall  spread  out  and  develop  in  accord- 
ance with  the  qualities  given  to  it  '  before  it  was  in  the  ground. '  I  did 
not  like  the  constraint  imposed  upon  me  by  the  presence  of  man.  I  did 
like  the  freedom  of  solitude.  I  strongly  disliked  many  things  I  noticed 
in  the  manner  and  words  of  some  I  met,  and  there  was  nothing  to  pre- 
vent this  dislike  from  occasionally  being  absorbed  into  my  solitary 
musings,  to  find  its  final  resolution  in  the  passion  of  indignation  in  its 
various  degrees  of  intensity  as  the  case  might  be.  I  have  spoken  before 
of  my  defective  means  of  defense  against  '  teasing '  or  mocking  for  the 
purpose  of  troubling.  I  was  always  terribly  alert  and  sensitive  to  all 
kinds  of  '  snubs '  and  sneers,  and  oblique  remarks  in  general,  on  their 

proficiency  in  which  some  people  pride  themselves  so  much 

I  was  also  disagreeably  impressed  by  the  ways  of  some  who  showed  a 
disposition  to  turn  their  attention  to  myself,  instead  of  confining  them- 
selves to  the  subject  I  was  presenting  to  them. 

"I  was  being  carried  into  a  state  of  secret  enmity  to  mankind  in 
general  by  the  prevailing  tenor  of  my  brooding  meditations,  and  there 
was  no  corrective  present. 

' '  But  all  received  a  hue  from  a  yearning  for  what  was  worthy 
in  life,  paired  with  a  mournful  sense  of  its  hopeless  absence.  What- 
ever wrong  turns  I  may  in  my  weakness  have  been  betrayed  into,  it  is 
impossible  that  I  should  look  upon  my  then  existing  frame  of  mind 
as  a  whole  with  repentant  feelings.  As  well  condemn  righteousness 
and  holiness  itself ! 

' '  When  I  admit  that  I  occasionally  was  overcome  with  an  irruption 
of  hard  feelings  toward  wrong-doing  man,  it  will,  of  course,  not  be 
understood   that   I   was   habitually   morose   and   spiteful    in   temper. 


PARANOIA.  1~>1 

Nothing  could  be  further  from  the  truth.  What  commotion  there  was 
was  mostly  internal,  rarely  reaching  the  surface  in  visible  ebullitions. 
.  .  .  .  I  occupied  myself  with  the  trifling  labors  of  my  garden, 
dwelling  with  interest  and  pleasure  on  the  progress  of  my  crops  and 
flowers,  and  every  now  and  then  took  a  ramble  over  to  the  woods  lying 
to  the  south,  which  were  a  favorite  place  of  resort  to  me  all  the  while  1 
lived  there.  There  I  botanized  and  moralized,  explored  the  recesses  of 
the  woods,  "enjoyed  the  calm  quiet  of  nature,  and  groaned  over  my 
hapless  condition,  wondering  what  it  was  to  come  to. 

"There  were  some  little  things  that  happened  to  me  the  first  year 
after  I  left  the  farm  which  became,  as  it  were,  a  kind  of  sample  of  what 
I  must  continue  to  expect,  and  the  memory  of  which  had  more  influ- 
ence   over   my  action  in  after  time  than   I  was  aware  of   myself,   no 

doubt When  I  was  around  the  city,  thinking  I  might  get 

employment  I  called  on  one  of  my  old  acquaintances,  who  was  then  in 
a  store.  I  talked  with  him  a  few  minutes  at  that  time.  I  called  again 
a  short  time  after,  when  I  was  told  by  the  proprietor  that  the  gentle- 
man I  had  called  to  see  was  not  in.  There  were  a  number  of  men 
present  in  the  store, — salesmen, — and  it  became  apparent  to  me  that  they 
were  trying  to  exhibit  an  offensive  demeanor  toward  me,  or  perhaps  it 
would  be  as  true  to  say  that  they  were  moved  to  make  a  derisive  de- 
monstration against  me.  At  all  events,  all,  with  perhaps  the  excep- 
tion of  the  proprietor,   stood  with  contortions  of   countenance,  which 

was  perhaps  laughter,  until  I  retired I  found  it  hard  to 

consign  this  to  forgetfulness.  At  first  it  lay  dormant,  but  it  would 
come  up,  and  I  must  confess  I  had  hard  feelings,  even  revengeful  feel- 
ings, toward  the  actors.  Another  thing  happened  the  same  fall.  I 
went  to  a  store,  and,  standing  at  the  counter,  was  noticed  by  one  of  the 
clerks, — an  Irishman, — who  came  to  me  and  said,  'I  always  wait  on  the 
little  boys  first,'  and,  as  I  took  no  notice  of  the  remark,  seemed  so  de- 
termined his  words  should  not  be  lost  on  me  that  he  repeated  them, 
with  the  addition,  'like  you.'  As  before,  it  produced  no  immediate 
effect,  but  it  afterward  rose  and  rankled  in  my  memory,  and  I  was  not 
able  to  keep  clear  of  imagining  vindictive  things.  In  fact,  to  tell  the 
truth,  in  both  cases  I  felt  that  blood  would  have  been  sweet  to  me. 
.     .     .     .     My  mode  of  thinking  on  these  incidents  no  doubt  had  in  it 

much  of  the  character  of  insanity The  effect  was  that  I 

got  settled  down  into  the  fixed  idea  that  contact  with  the  thoughtless, 
evil  world,  in  my  state  of  body  and  mind,  would  impose  upon  me  the 

necessity  of  committing  crime  in  vindication  of  my  honor 

I  let  these  bloody  memories  tinge  my  whole  mind,  and  all  its  anticipa- 
tions and  resolutions  for  the  future 'I  see, '  I  said  to  my- 
self, in  substance,  '  that  these  galling  collisions  are  the  natural  penalties 
of  being  imperfect. ' 

' '  It  may  be  as  well,  for  the  prevention  of  misconceptions,  to  say 
that  I  never  took  one  step  toward  putting  any  design  thence  arising 
into  execution.  I  had  no  designs.  I  never  armed  myself,  or,  in  fact, 
went  any  further  than  to  rehearse  the  drama  of  revenge  in  my  own 
mind.  The  pistol  I  bought  was  one  which  I  would  not  have  trusted  for 
a  moment  to  carry  for  the  purpose  of  self-defense Never- 
theless, the  events  on  the  farm  show  that  my  wickedness  was  not 
altogether  of  a  mimic  kind,  and  I  will  not  attempt  to  escape  righteous 
judgment. 


758  MENTAL   DISEASES. 

' '  I  used  to  make  many  resolutions  about  regularity  in  habits  of  eat- 
ing, which  I  found  myself  powerless  to  keep.  A  sense  of  depression 
and  vacuity  would  come  over  me,  aggravated  by  my  solitary,  monoto- 
nous life,  I  presume,  and  often  by  an  obstructed  state  of  the  alimentary 

organs It  is  a  common  feature  in  insanity  or  semi-insanity 

left  to  itself,  I  think.  I  also  exerted  my  brain  to  the  extent  of  abuse, 
I  know,  in  the  way  of  study.     ...  I  used  to  study  Latin  for  a 

pastime,  and  often  kept  cudgeling  my  brains  over  Cicero  and  Caesar 
until  the  top  of  my  head  was  very  sore.  This  solitary  immersing  of 
an  enfeebled  mind  in  study,  with  obliviousness  to  myself  and  all  sur- 
roundings, was,  no  doubt,  a  help  toward  the  grand  consummation  that 

took  place  in  the  fullness  of  things I  suffered  a  good  deal 

from  bodily  ailments.  My  liver  seemed  to  be  thoroughly  out  of  order 
and  torpid.  I  had  a  feeling  of  hardness  and  inflammation  in  my  sides 
regularly,  a  certain  length  of  time  after  meals  ;  digestion  was  bad, 
appetite  irregular — in  fact,  every  sign  of  a  deadlock  in  the  vital  func- 
tions. ' ' 

His  mother  and  he  removed  to  another  village  in  1871,  when  he 
was  twenty-eight  years  of  age,  by  which  time  there  was  but  little 
question  of  his  insanity,  even  among  his  relatives.  I  let  him  take  the 
thread  of  the  story  again  at  this  epoch  : 

' '  When  my  mother  was  making  preparations  for  moving  she  asked 
me  to  help  in  packing  up  some  chairs.  I  made  an  effort  to  apply  my- 
self to  the  task,  but  suddenly  found  myself  overcome  by  my  feelings, 
and  before  I  knew  what  I  was  about  I  had  shivered  one  of  the  chairs  to 
fragments.  A  most  unpromising  omen  !  The  fact  is  that  I  was,  and 
had  been  for  some  time,  in  a  state  which  any  physician,  knowing  the 
facts,  would  have  pronounced  to  be  unmistakable  insanity.  But  I 
had  different  ideas  about  what  constituted  insanity,  and  often  thought 
to  myself  that  if  I  did  get  put  into  an  asylum,  as  had  been  threatened, 
they  would  not  keep  me,  because  they  would  see  that  I  was  perfectly 
rational.     I  have  learned  more  about  the  subject  since. 

"  Things  of  the  kind  I  have  told  of  had  happened  to  me  before,  at 
uncertain  intervals,  during  several  years,  an  obstructed  state  of  the 
bowels  bringing  on  a  turn.  I  would  get  into  such  a  condition  of  exag- 
gerated discomfort  as  to  lose  for  a  moment,  or  sometimes  quite  a  spell, 
my  control  over  my  actions,  and  act  very  strangely.  Sometimes  I 
dashed  down  an  article  I  happened  to  have  in  my  hands,  or  demolished 
the  first  thing  that  came  to  hand;  sometimes  I  gave  vent  to  my  feelings 
by  grating  my  teeth,  '  clawing '  my  face,  and  going  through  strange 
grimaces  and  agonizing  contortions.  My  face  seemed  to  me  to  be  par- 
alyzed when  I  had  such  turns,  as  if  lifeless.  The  worst  thing  I  ever 
did  was  when  I  flew  at  my  mother  in  a  sudden  access  of  frenzy  one  day, 
when  she  had  wrought  upon  my  feelings  by  talking  to  me  irritatingly, 
and  bit  out  a  mouthful  of  her  hair.  .  .  .  When  I  was  committed 
to  the  asylum,  at  a  later  day,  it  was  reported  as  one  of  my  symptoms 
that  I  had  delusions  about  my  mother  being  my  enemy,  etc. ,  but  noth- 
ing could  be  further  from  the  truth.  ...  I  often  grieved  in  secret 
over  my  inability  to  be  a  stay  and  protection  to  her,  bereft  as  she  was 
of  all  other  support,  but  all  in  vain. 

' '  In  my  new  home  I  was  in  one  of  a  row  of  houses,  with  strangers 


I'MtANOIA.  759 

living  near  on  both  sides,  and  the  sense  of  the  presence  of  the  evil 
which  I  had  shrunk  from  so  longweighed  down  upon  me  with  crushing 
weight.      After  a  while    my    spell    of    hypochondriacal    despondency 

passed  off,  and  I  settled  down  into  the  way  of  living  which  1  adhered 
to  as  long  as  I  remained  there.  As  to  getting  acquainted  with  my 
neighbors,  or  having  any  intercourse  or  dealings  with  them,  that  was 
altogether  out  of  the  question.  ...  I  now  had  more  of  the  feeling 
of  constraint,  from  the  knowledge  that  1  was  moving  under  the  eyee  of 
people  who  were  strangers  to  me,  than  the  strangest  of  the  strange 
could  be  to  a  person  of  the  ordinary  stamp.  Sometimes  I  heard  re- 
marks which  did  not  affect  my  feelings  flatteringly,  but  that  was  not 
common. 

'  'Along  in  June  I  had  a  worse  spell  than  common  of  the  kind  of 
nervous  stagnation  or  will-impotence  of  which  I  have  spoken,  and  per- 
petrated some  quite  irregular  acts  before  my  fetters  became  slackened. 
In  my  despair  I  tore  the  collar  from  my  shirt,  tore  the  slippers  I  was 
wearing,  dashed  my  fist  into  a  tempting  dish  which  my  mother  was 
offering  me  to  eat,  and  other  things  of  the  kind.  The  house  we  occu- 
pied was  owned  by  a  maiden  lady  who  lived  with  her  sister  in  part  of 
the  house.  ...  In  the  evening,  after  the  other  sister  returned, 
who  had  been  absent  during  the  day,  I  overheard  a  few  words  which 
showed  plainly  enough  that  the  events  of  the  day  were  being  discussed 
in  no  very  gratified  humor.  It  was  evident  that  my  acts  were  severely 
reprobated." 

The  next  day  the  justice  of  the  peace  called  upon  him  and  admonished 
him  to  restrain  himself,  hinting  of  the  asylum.     Of  this  our  author 

says  : 

"The  dragon's  tooth  of  reprimand  that  had  been  left  in  my  mind 
grew  into  a  monster,  in  whose  presence  I  found  it  impossible  to  live, 
and  I  had  a  fresh  access  of  despair.  It  was  a  hot  June  morning.  I  re- 
member seizing  a  razor  and  flourishing  it,  and  saying,  '  Show  me  that 
rascal  and  I  will  slaughter  him, '  or  words  to  that  effect,  meaning,  of 
course,  the  justice  of  the  peace." 

Both  homicidal  and  suicidal  inclinations  had  long  been  haunting  the 
secret  corners  of  his  mind,  for  three  years  before  he  tells  of  buying  a 
pistol  for  the  express  purpose  of  making  way  with  himself  or  some  one 
else.  On  this  day,  after  meeting  the  officer,  he  determined  upon  suicide. 
He  walked  out  to  two  different  country  stores  and  bought  ammunition. 
On  his  way  back  he  passed  some  men  in  a  field.  They  all  looked  at 
him,  and  one  of  them  "  laughed  loud  and  mockingly,  and  then  cried  out, 
in  a  sort  of  squealing  way,  the  intention  of  which  could  not  be  mis- 
taken." Then  he  played  a  game  of  croquet  with  a  young  man  at  his 
uncle's,  and  overheard  the  young  man  make  a  covert  and  derisive  re- 
mark.    He  continues  : 

' '  I  passed  the  next  day  in  brooding,  silent  melancholy.  It  was  a 
rainy  day  and  in  accord  with  my  feelings.  .  .  .  That  night  I 
wrote  a  little  statement  to  be  left  behind.  ...  It  can  not  be  said 
that  I  plunged  thoughtlessly  into  the  gulf  of  self-murder.  I  had  from 
the  first  gaged  the  responsibility  I  was  taking  on  myself,   as  fully  as 


760  MENTAL   DISEASES. 

my  mind  was  capable  of  doing  it.  I  felt  the  whole  weight  of  the  con- 
demnation that  rested  upon  me  for  committing  such  a  deed. 
I  passed  some  part  of  the  hours  of  the  night  in  sleep.  In  the  morning 
my  mother  came  to  the  door  to  see  how  I  was,  and  I  grasped  her  hand 
with  a  gesture  of  agonized  despair.  She  took  it  as  an  indication  that  I 
was  going  to  have  one  of  my  wild  spells  again,  and,  as  she  told  me 
afterward,  began  to  anticipate  some  work  of  demolition  after  I  should 
come  down-stairs.  After  she  had  gone  down,  I  went  and  took  the  pistol 
from  the  stand-drawer,  put  on  a  fresh  cap,  got  into  bed  again  and 
propped  up  my  head  on  the  pillows,  placed  the  muzzle  of  the  pistol 
against  the  center  of  my  forehead,  and  fired." 

He  lost  considerable  blood  from  the  scalp-wound,  but  the  bullet  had 
glanced  off;  and,  although  he  now  tried  to  starve  himself,  he  was  up 
and  about  in  a  few  days  as  usual,  attending  to  his  garden  with  bandaged 
forehead.     He  continues  : 

' '  There  were  some  steps  taken  toward  getting  me  into  an  asylum 
after  my  abortive  attempt  at  suicide,  but  as  there  were  difficulties  about 
it,  and  I  appeared  perfectly  sensible  and  rational,  my  relatives  concluded 
to  let  it  rest. 

' '  From  the  time  of  my  shooting  until  the  next  spring  there  was  not 
much  that  deserves  mention.  How  were  my  thoughts  about  suicide  ? 
It  must  be  said  that  I  had  not  totally  renounced  that  idea. 
I  used  very  often  to  scan  the  beams  in  the  wood-house  and  the  coils  of 
clothes-line  in  the  garret.  .  .  .  The  old  difficulty  of  giving  way 
under  the  slighting  or  displeasing  demonstrations  from  others  remained 
as  bad  as  ever.  I  remember  once  I  was  so  wrought  upon  by  some 
trifling  thing  said  or  done  by  one  of  my  relations  that  I  kicked  out  the 
bottom  of  a  cane-seat  chair  I  was  resting  my  feet  on,  in  a  sudden  par- 
oxysm of  impotent  emotion." 

About  this  time  he  also  made  a  futile  attempt  to  poison  himself  by 
drinking  a  bottle  of  strong  tincture  of  valerian  that  he  had  made 
himself.     That  incident  he  describes,  and  then  proceeds  : 

' '  It  was  my  intention,  when  I  began  this  sketch  of  my  life,  to  give 
greatest  prominence  to  that  part  beginning  with  my  troubles  in  Clinton 
Street — that  is  to  say,  the  period  of  confirmed  lunacy  with  hallucinations, 
according  to  the  world's  avowed  decision;  but  it  appears  at  present  that 
my  project  is  not  to  go  into  fulfilment.  I  have  been  greatly  delayed  in 
doing  as  much  as  I  have  by  lack  of  strength. 

' '  To  make  the  account  which  I  have  given  as  full  an  exhibition  of 
my  condition  at  the  time  my  hallucinations,  if  such,  appeared,  I  will 
note  some  further  defects  in  my  mental  action  which  I  had  noticed  up 
to  this  time.  First,  two  or  three  things  indicating  original  lack  of 
control  over  the  brain  by  the  will,  or  non-identification  of  my  will  with 
the  action  of  my  brain,  and  which  I  must  count  for  predisposition. 
I  have  been  troubled  from  my  boyhood  with  a  tendency  of  my  brain  to 
see  things  it  ought  not  to  see  in  what  is  placed  before  my  eyes.  This 
refractoriness  does  not  extend  to  all  kinds  of  monstrous  visions,  but  is 
limited  to  the  singling  out  of  the  lineaments  of  the  human  face  in  the 
outlines  of  objects  seen.     The  annoyance  I  have  experienced  from  this 


PARANOIA.  7(J1 

has  varied  greatly,  according  to  the  state  of  my  health.  When  I  used 
to  be  sick  with  the  fever  and  ague,  J  would  lie  in  bed  and  gaze  at  the 
coarsely  daubed  window-shades  in  my  bedroom,  until  I  had  made  out 
every  possible  kind  of  a  profile  that  could  be  distinguished. 

"The  other  of  the  two  most  serious  abnormal  peculiarities  is  the 
supplying  of  missing  articulations  to  vocal  sounds,  heard  but  not 
understood  distinctly,  so  as  to  give  my  mind  the  impression  of  certain 
words,  at  the  same  time  that  I  knew  I  had  not  understood.  Sometimes 
I  have  been  really  cheated  this  way,  and  only  found  it  out  by  inquiring 
afterward.  This  might  not  give  conclusive  proof  of  the  deception,  it  is 
true.  Not  to  violate  privacies,  I  will  illustrate  supposititiously.  If 
it  were  proclaimed  aloud,  far  enough  from  me  to  allow  the  inflections 
but  not  the  articulations  to  reach  my  ear  with  certainty — 

We  See  Where  Lies  the  Dreadful  Secret  ! 

my  mind  might  involuntarily  and  instantaneously  reshape  it  in  such  a 
way  that  I  would  understand  : 

Deceive  Where  Lies  Were  Ever  Sacred  ! 

"My  attention  was  always  quite  easily  disturbed  by  noises,  par- 
ticularly talking.  In  boyhood  the  sound  of  voices  in  conversation  at  a 
little  distance  after  I  had  retired  to  rest  often  gave  me  very  serious 
annoyance,  showing  excessive  irritability  of  the  brain. 

' '  Such  was  my  mental  state  on  the  eve  of  my  being  overtaken  by  a 
more  marvelously  awful  fate  than  ever  fell  to  the  lot  of  mortal  man. 

' '  My  original  purpose  was  to  follow  the  incidents  having  a  bearing 
on  my  mental  fortunes  with  tolerable  minuteness,  in  an  unbroken  chain, 
up  to  the  time  of  reaching  that  wonderful  state  in  which  I  have  existed 
for  the  last  six  and  one-half  years. 

' '  I  shall  be  obliged  to  confine  myself  more  to  generalities. 

"I  was  in  such  a  towering  state  of  morbid  sensitiveness  that  a  slight 
tinge  of  impertinence,  brusqueness,  or  fancied  contemptuousness  in  the 
manner  of  those  I  met,  put  me  on  the  rack  at  once.  ...  It  began 
to  occur  to  me  after  a  little  that  my  ears  were  becoming  wonderfully 
.acute  for  such  things.  Very  often  I  would  hear  lively  discussions  on 
my  character,  and  disputes  about  the  proper  epithets  and  titles  to  be 
applied  to  me,  which  I  understood  perfectly  at  an  astonishing  distance 
off.  _ .  .  .  I  was  wrought  up  to  such  a  pitch  that  I  formed  a  resolve 
that  if  I  were  given  a  sufficiently  open  provocation,  I  would  attempt  a 
bloody  revenge,  and  on  one  occasion  went  out  with  a  razor  in  my 
pocket.  ...  I  had  an  oppressive  feeling  of  impotence,  as  if  para- 
lyzed^ and  suddenly  did  things  I  had  no  intention  of  doing,  as  in 
breaking  glass.  ...  I  had  a  soreness  all  through  my  limbs  which 
I  compared  to  molten  fire  running  through  my  nerves. 

"I  began  to  hear  responses  to  and  comments  on  my  performances, 
and  it  gradually  dawned  upon  me  that  I  had  been  making  myself  a 
conspicuous  object  of  curiosity  to  the  whole  neighborhood.  .  .  .  The 
comments  heard  grew  more  numerous  and  more  and  more  derisive.  .  .  . 
I  had  no  suspicion  at  the  time  of  any  of  the  inspiration  being  drawn 
directly  from  my  head.  I  do  not  say  it  was  so.  This  is  the  debatable 
ground.    ...    It  was  not  until  about  a  week  later  that  it  became  evident 


762  MENTAL  DISEASES. 

to  me  that  I  was  hearing  my  own   thoughts  given  expression  to  by- 
foreign  wills  and  voices. 

' '  I  heard  a  great  deal  about  '  inducting, '  '  conducting, '  '  sphere  of 
influence, '  sometimes  even  '  poles, '  positive  and  negative,  and  my  brain 
was  constantly  compared  to  a  magnet.  ...  I  could  find  no  better 
explanation  myself  for  a  long  time  than  the  theory  of  a  fluid,  similar  to 
or  the  same  as  electricity,  uniting  brains. 

' '  One  was  the  story  of  an  English  physician  who  had  become  ac- 
quainted with  my  magnetic  properties,  and  who  was  on  the  spot  at  the 
beginning,  directing  the  experiment.  He  was  stated  to  have  been  the 
first  to  form  a  perfect  communication  with  the  inducted  brain,  and  he 
had  drawn  off  my  entire  memory  back  to  childhood,  and  had  delivered 
it  verbally  in  the  presence  of  reporters  from  the  city,  who  had  taken  it 
down.  It  was  stated  that  the  record  was  preserved  in  a  number  of  thick 
volumes.  These  he  had  taken  with  him  when  he  sailed  for  England 
during  the  most  prosperous  part  of  the  experiment.  It  was  further 
asserted  that  he  continued  in  communication  with  my  thoughts,  and 
that  wherever  he  went  every  one  to  whom  he  told  the  story  of  the  new 
marvel  was  also  set  in  connection  with  the  magnetic  current  flowing 
from  my  head,  and  began  to  participate  in  my  thoughts.  .  .  .  One 
word  more  of  the  English  doctor.  He  is  said  to  have  declared  that  if 
he  had  assisted  at  my  birth  he  would  not  have  suffered  me  to  remain 
alive,  as  the  monstrous  character  of  my  organization  could  have  been 
seen  at  a  glance.  .  .  .  After  the  whole  earth  had  become  pervaded 
with  the  magnetism  from  my  head,  it  would  be  felt  as  long  as  I  lived, 
and  the  instant  of  my  death  would  be  thus  signaled  all  over  the  globe, 
and  would  be  noted  and  used  by  all  nations  as  a  new  era  from  which  to 
reckon  time. 

"  I  would  think  of  the  Bible,  go  and  open  it  at  haphazard,  and  just 
where  my  eye  fell  there  was  a  passage  that  showed  me  myself.  Once 
when  I  had  been  fretting  about  my  ill  success  in  getting  my  mother  to 
accord  with  my  views  about  my  neighbors'  doings,  I  hit  upon  this  : 

"  'And  it  shall  come  to  pass  that  when  any  shall  yet  prophesy,  then 
his  father  and  his  mother  that  begat  him  shall,  say  unto  him,  Thou 
shalt  not  live,  for  thou  speakest  lies  in  the  name  of  the  Lord  ;  and  his. 
father  and  his  mother  that  begat  him  shall  thrust  him  through  when 
he  prophesieth' ,  etc. — Zechariah,  xiii. 

"But  the  most  perfect  identity  of  all  is  to  be  found  scattered 
through  the  Psalms ' '  [of  which  he  quotes  several  pages,  and  then  con- 
tinues] :  "  I  do  not  intend  to  appropriate  the  spirit  of  these  passages, 
or  to  make  their  language  my  own,  but  quote  them  thus  collectively  as- 
an  evidence  of  fact.  I  am  myself  but  an  inquirer.  Do  they  express 
the  experience  of  any  certain  person  or  persons?  Or  are  they  pro- 
phetic ?  .  .  .  Can  it  be  that  the  same  thing  that  has  happened  to 
me  has  befallen  another  in  ages  long  past,  and  that  these  are  the  traces 
of  it? 

' '  I  have  also  found  a  most  remarkably  close  application  of  many 
of  the  precepts  and  reflections  of  Thomas  a  Kempis  in  his  '  Imitation 
of  Christ.'  He  seems  to  keep  the  same  character  exhibited  in  the 
Psalms  in  view,  only  speaking  as  a  monitor,  instead  of  in  his  person. 
I  presume  I  find  myself  mirrored  in  both  these  places,  because  I  am 
an  extreme  case." 

Gradually  his  delusions,  burgeoning  one  from   another,  became  so 


PARANOIA.  763 

systematized  that  in  the  last  year  of  his  stay  at  this  asylum  he  could 
write  in  his  book  : 

"The  signs  are  too  many  and  too  evident  to  permit  me  to  doubl 
that  my  destiny  is  bound  up  with  the  religion  of  the  world.  I  stead- 
fastly believe  that  the  words  in  Jeremiah,  '  Take  forth  the  precious 
from  the  vile,]  are  addressed  to  me;  and  I  can  not  be  recreant  to  the 
holiest  of  duties.  ...  I  will  not  waste  time  in  useless  discussion, 
but  start  with  the  assumption  that  it  is  God's  will  that  I  should  give 
the  world  my  opinions. 

"If  it  comes  to  be  generally  believed  that  my  sign  is  a  fulfilment 
of  Hebrew  prophecy,  I  would  recommend  a  transfer  [of  the  Sabbath] 
to  the  day  of  the  commandment.  The  very  fact  of  a  day  one  step  re- 
moved being  fixed  on  by  both  Christians  and  Mohammedans  looks  like 
an  admission  that  another  step  remained  to  be  taken. 

' '  Was  it  not  the  confidence  of  Jesus  in  the  book  spoken  of  above 
that  made  him  say  he  knew  the  Father,  when  contending  with  believers 
in  personified  derangement  ?  ' ' 

Quite  a  large  part  of  the  volume  is  devoted  to  expounding  the  Scrip- 
tures, in  accordance  with  his  delusion  that  he  is  a  prophet  come  to  re- 
veal a  new  religion. 

For  instance,  of  Babel  he  says : 

' '  I  find  an  application  for  the  tower  of  Babel  in  my  own  insane 
history.  I  expect  a  confusion  of  the  speech  of  the  old  sects  to  ensue 
likewise. ' ' 

Of  Abraham  he  remarks  : 

' '  Abraham  is  accounted  the  father  of  all  who  believe  in  the  Eternal. 
I  believe  I  am  chosen  as  his  sign  for  the  abolition  of  all  dishonoring 
beliefs,  as  Abraham  was  set  up  against  all  idolators  and  pagans.  .  .  . 
I  have  to  note,  in  connection  with  the  offering  of  Isaac  by  Abraham,  that 
I  find  the  date  given  as  1872  before  Christ,  coinciding  with  the  year 
after  Christ  in  which  my  ear-troubles  commenced." 

Of  Esau : 

' l  We  may  take  Esau  for  polytheistic  religion,  recognizing  and  deify- 
ing every  force  and  passion  that  has  dominion  over  the  soul  and  destiny 
of  man.  .  .  .  When  it  gave  up  its  birthright  for  belief  in  a  single 
judge,  it  pledged  itself  to  go  on  and  submit  to  be  judged  by  the  new 
master.     I  believe  that  the  day  of  judgment  has  come." 

Of  the  miracle  of  the  rods  : 

' '  The  rods  changed  into  serpents  signify  arguments  becoming  living 
convictions  in  the  mind  of  Pharaoh.  The  evangelists'  rods  live  as  ser- 
pents in  the  minds  of  Christian  believers,  but  I  confidently  expect  that 
my  rod  will  become  a  serpent  that  will  swallow  them  all  without  trouble. 

"Israelis  held  responsible  for  the  destruction  of  the  heathen  and 
their  idols.     I  conceive  that  I  am  the  Lord's  instrument  for  the  com- 


764  MENTAL   DISEASES. 

pletion  of  this  work,  and  that  I  have  been  shown  these  signs  in  the  law 
that  my  hands  might  be  strengthened. 

' '  I  can  not  shut  my  eyes  to  the  fact  that  I  have  been  made  the 
world' s  sin-offering. ' ' 

Of  the  prophets  : 

' '  The  prophets  I  will  take  in  a  lump,  with  the  assurance  that  no 
one  can  fail  to  see  their  connection  with  my  destiny.  There  is  a 
prophecy  in  Ezekiel,  xxxiii,  30,  which  is  very  closely  paralleled  in  my 
experience.     .     .     .     Jonah  gives  me  a  parable. ' ' 

His  discussions  of  theological  questions  are  interesting,  perfectly 
coherent  and  logical,  although  often  fanciful.  He  pays  tribute  to  the 
beautiful  moral  laws  and  righteousness  of  Christ,  but  is  disposed  to 
criticize  His  conduct  as  being  inconsistent  in  one  who  claimed  to  partake 
of  the  omnipotence  and  omniscience  of  the  Eternal.  Of  resurrection  he 
says  : 

"If  I  conceive  of  a  new  body  having  the  memory  which  I  have  of 
this  body's  life, — and  I  can  find  no  other  idea  of  the  continuance  of  a 
soul's  life  except  in  the  perpetuation  or  renewal  of  the  memory, — would 
that  in  the  new  body  be  a  true  memory  ?  Would  it  not  be  a  hallucina- 
tion ?     Would  not  that  be  an  insane  creation  ? ' ' 

In  speaking  of  the  years  of  his  greatest  mental  aberration,  he  says  : 

' '  Here  I  come  to  more  debatable  territory,  on  which  I  and  the  rest 
of  the  world  have  until  this  present  been  at  variance.  I  will,  in  defer- 
ence to  the  other  side,  make  use  of  the  word  believe  in  stating  facts  drawn 
from  the  region  of  my  memory  lying  within  this  shadowy  world.  I 
will  be  permitted  to  say,  therefore,  that  I  believe  that  after  settling 
down  in  the  before-mentioned  place,  my  brain  was,  by  the  gradual 
progress  of  events  occurring  naturally  and  according  to  the  ordinary 
laws  of  human  affairs,  drawn  into  relations  to  the  living  actors  around 
me,  of  an  altogether  unexampled  kind — at  all  events,  different  from  any- 
thing plainly  recorded  in  the  annals  of  past  ages.  I  believe  that  the  final 
result  of  such  relations  was  the  superinducing  of  a  state  of  mental  inter- 
communication through  the  medium  of  my  sense  of  hearing. 

"  But  this  is  a  very  old  story,  and  merely  a  restatement  of  the  per- 
fectly well-known  features  of  my  alleged  monomania.  Let  me  pass  on 
and  give,  as  well  as  I  am  able,  my  own  theory  on  which  I  explain  these 
phenomena,  which  may  have  more  interest.  It  is  a  question  of  personal 
identification.  How  does  a  man  use  his  own  brain  ?  He  can  use  it 
because  it  recognizes  the  actions  of  his  members  as  belonging  to  the  per- 
sonal unit  of  which  it  forms  the  summit.  Now  the  question  is,  can  not 
a  human  brain  under  certain  circumstances  become  so  perverted  as  to 
recognize  for  itself,  and  without  the  volition  of  its  bearer,  the  acts  of 
other  individuals  as  belonging  to  its  life,  as  falling  within  its  own 
memory  ?  And  if  so,  would  not  those  individuals  become  partakers  of 
the  intellectuality  of  that  brain,  know  its  conceptions  and  ideas,  while 
it  thus  recognized  their  motions,  and  become  able  to  share  its  walks  and 
ways  ?  Such  I  believe  to  have  been  the  result  in  myself,  from  the 
towering  height  of  disintegration  reached  by  my  mental  organism,  by 


PARANOIA.  765 

the  gradual  process  which  I  have  endeavored  to  faintly  shadow  forth  in 
the  preceding  five  chapters. 

"Let  us  see  whether  it  does  not  look  probable  that  a  mind  in  the 
habit  of  separating  recognized  observations  from  its  own  responsibility, 
considering  them  objectively,  philosophizing  on  its  own  manner  of 
working,  driving  the  impotent  and  erratically  acting  part  into  a  comer, 
as  it  were,  would  not  be  more  exposed  to  such  a  fate  as  supposed  than 
one  acting  unitedly,  and  right  or  wrong  as  a  unit.  It  may  not  be  sus- 
ceptible of  argument  based  on  points  of  organic  action,  but  it  looks  a 
plausible  thing  to  me  that  the  insane  quality  or  element  in  such  a  brain 
might  be  acted  on  from  without,  and  give  itself  up  to  such  action,  inde- 
pendent of  the  thinking  will  of  that  mind. 

' '  But  let  us  further  suppose  some  little  abnormality  about  the 
original  constitution,  a  predisposition  from  a  slightly  dislocated  arrange- 
ment of  mind-apparatus  and  sense-apparatus. 

1 '  Such,  say  I  once  more,  I  believe  to  have  been  the  case  with  myself, 
and  such  to  be  the  true  nature  and  essence  of  the  things  which  have 
constituted  my  insanity.  .  .  .  I  do  not  deny  the  fact  of  insanity, 
but  I  firmly  believe  that  it  is  and  has  been,  since  the  summer  of  1872, 
an  insanity  involving  the  will,  ideas,  and  acts  of  more  than  one  indi- 
vidual. 

' '  Notwithstanding  my  full  and  necessary  faith  in  the  reality  of 
things  as  I  have  reasoned  to  prove  them,  I  am  still  willing  to  concede 
that  there  has  been  more  or  less  of  purely  subjective  illusion  mingled 
with  these  dual  realities.  Under  one  aspect  the  whole  of  this  train  of 
mental  images  and  impressions  which  has  whirled  through  my  head 
has  consisted  of  insane  delusion.  The  effect  on  the  state  of  my  system 
has  no  doubt  been  analogous  to  that  produced  by  delusions,  and  the 
nervous  condition  which  preceded  it  was  such  as  eventuates  in  the  rise 
of  delusions.  Does  not  the  development  of  delusions  often  have  a  com- 
pensating effect  in  freeing  the  nervous  system  in  a  manner  from  its 
trammels  ?  Perhaps  when  this  supervenes  the  brain  becomes  a  chim- 
ney for  the  combustion  of  the  matters  which  threatened  to  entirely  in- 
terrupt the  action  of  the  system  by  clogging.  The  patient  is  then 
known  as  sensible  on  most  subjects,  but  a  confirmed  monomaniac." 

Certain  peculiarities  in  his  hallucinations  possess  considerable  in- 
terest. They  almost  always  referred  to  the  intercommunication  of 
brains.  In  July,  1878,  he  wrote  out  a  list  of  specimen  phrases 
which  he  had  heard  while  sitting  alone  at  an  asylum  window.  Some 
of  these  I  reproduce  here  : 

"  One  thing  you  know,  you  know  when  you  get  your  will  in  there 
you  get  him  into  a  hell  of  misery." — "He  ain't  got  any  will  there  to 
fool  away. " — "Although  you  are  knowing  his  ideas  you  connect  •with 
her  will." — "  Instead  of  connecting  with  his  ideas  you  keep  giving  him 
to  her." — "You  can't  get  your  will  there  till  he  connects  his  through 
to  his  thought." — "We  are  all  the  while  trying  to  make  him  think 
himself." — "  I  think  we  ought  to  be  making  efforts  to  get  the  idea  out 
on  the  hall." — "After  they  get  the  whole  will  he  is  in  a  hell  of  torture 
all  the  while." — "We  keep  hollering  till  we  get  him  into  a  hell  of  hor- 
rors."— "  You  see,  when  there  are  two  wills  connected  with  the  head  at 
the  same  time,  he  ain't  nowhere." 


766  MENTAL   DISEASES. 

These  were  the  voices  of  several  men  and  women.  In  fact,  his  hal- 
lucinations were  always  polyphonic,  and  at  times  would  be  polyglot. 
They  did  not  address  him  directly,  but  spoke  to  one  another  about  him. 
He  seldom  had  hallucinations  of  hearing  except  when  the  ear  actually 
received  the  sound  of  distant  conversation  or  inarticulate  noises  ;  so  that 
for  their  production  it  was  usually  necessary  that  there  should  be  trans- 
mission of  vibrations  to  the  auditory  cortical  area.  As  instances  of  the 
polyglot  character  of  the  voices  on  occasion,  I  relate  the  following  : 

Once  he  heard  some  one  call  out,  "  If  he  ain't  a  prophet  there  never 
was  a  prophet — tabulas  dedi  ut  vincerer."  In  tracing  this  Latin  to  its 
source,  he  found  it  was  a  perversion  of  a  phrase  in  a  note  to  Wins- 
ton's "  Josephus  "  :  "  Egomet  tabulas  detuli  ut  vincerer  "  (I  myself  car- 
ried the  letter  commanding  that  I  be  bound),  attributed  to  Bellerophon, 
which  he  had  once  read. 

At  another  time  in  a  street-car,  a  German  sitting  next  to  him  cried 
out,  "  Das  ist  das  grosste  Mirakel  von  der  ganzen  Welt.  Jeder 
Gedanke  der  ihm  in  den  Kopf  gekommen  ist  hat  die  ganze  Village 
gehort."  (That  is  the  greatest  miracle  in  the  world.  The  whole  vil- 
lage has  heard  every  thought  that  has  come  into  his  head.)  The  gram- 
matical construction  of  the  foreign  phrases  is  open  to  criticism.  The 
language  used  by  his  invisible  tormentors  was  always  a  peculiar  dialect, 
often  abounding  in  slang,  which  he  considered  the  most  hateful  kind 
of  language,  and  which  was  such  as  he  never  voluntarily  used  in  the 
composition  of  his  own  sentences.  The  hallucinations  were  usually 
boisterously  satirical,  teasing,  quizzical,  frequently  accompanied  by 
laughter. 

Course  and  Prognosis. — The  usual  course  of  paranoia  has  just 
been  outlined.  Many  cases,  however,  enter  into  a  state  of  secondary 
dementia  toward  the  last. 

The  prognosis  is  absolutely  unfavorable.  I  do  not  know  of  a  single 
case  that  has  recovered.  These  patients  may  live  to  an  advanced  age, 
especially  under  the  fostering  care  of  an  asylum.  Remissions  are 
occasionally  noted. 

Morbid  Anatomy. — The  disorder  is  purely  functional.  No  patho- 
logical changes  have  been  found  in  the  brains  of  paranoiacs.  In  some 
instances  asymmetrical  arrangement  of  the  convolutions  has  been  noted. 
These  belong  in  the  category  of  stigmata  of  degeneration. 

Treatment. — Therapy  does  little  or  nothing  for  the  disease  once  it 
has  become  established.  Sometimes  complete  change  of  environment 
brings  about  a  remission.  Constant  physical  occupation,  hard  work 
out-of-doors,  is  perhaps  the  most  useful  of  remedial  agents,  in  that  by 
this  means  the  mind  is  diverted  from  the  constant  contemplation  of 
hallucinations  and  delusions,  and  through  bodily  fatigue  is  made  to 
receive  a  considerable  amount  of  repose.  Labor  acts  as  a  counterirri- 
tant.  By  it  episodic  outbreaks  of  excitement  may  be  aborted  or 
reduced  in  intensity.  Prevention  naturally  would  be  of  vast  impor- 
tance, were  one  able  to  anticipate  the  coming  catastrophe  in  the  pro- 
dromal period.  Children  and  youths  who  exhibit  such  symptoms  as 
have  been  described  as  incident  to  the  hypochondriacal  epoch   of  the 


IDIOCY.  707 

evolution  of  paranoia  require  a  special  system  of  education  and  train- 
ing, in  which  occupation  of  the  muscles  and  out-of-door  life  should 
play  the  chief  role. 


CHAPTER  XIII. 
IDIOCY. 

Definition. — In  attempting  to  make  a  good  definition  and  prepare 
a  classification  of  idiocy,  we  meet  with  much  the  same  difficulties  as 
exist  in  connection  with  the  allied  subject  of  insanity.  The  innum- 
erable definitions  and  classifications  of  insanity  by  different  authorities 
are  familiar  to  all  students  of  morbid  psychology.  Each  author  feels 
called  upon  to  be  original  in  this  particular,  or  at  least  to  modify  and 
improve  upon  the  dicta  of  previous  writers.  This  confusion  is  quite 
parallel  in  the  matter  of  idiocy  ;  and  it  is  easy  to  understand  why  this 
should  be  so,  for  in  both  conditions  we  have  deviations  from  the  normal 
mental  state  of  every  possible  shade  and  degree,  depending  upon  a  most 
varied  pathology.  The  etiology  is  complex,  and  the  psychic  and 
somatic  symptomatology  multiform.  There  is  no  wonder,  then,  that 
the  clinical  picture  is  hard  to  draw,  and  the  arrangement  into  clinical 
types  difficult  in  the  extreme.  It  is  impossible  to  make  any  comparison 
between  the  psychological  state  of  idiots  and  that  of  normal  children, 
for  the  former  is  not  only  one  in  which  the  mental  faculties  are 
diversely  undeveloped  or  impaired  as  regards  their  quantity,  but  there 
is  infinite  variation  in  the  quality  of  the  idiot's  psychic  functions. 
Likewise  it  is  impossible  to  contrast  the  mental  organization  of  the  idiot 
with  the  intelligence  of  the  lower  animals,  for  the  idiot  is  always 
abnormal,  while  the  animal  is  a  normal  being  in  the  zoological  series  to 
which  he  belongs. 

What  seems  to  be  desirable  in  a  definition  is  that  there  should  be 
expressed  in  it  the  condition  of  mental  weakness  existing,  the  facts  that 
the  condition  may  be  congenital  or  acquired,  and  may  be  due  to  a 
defect  or  some  disease  of  the  brain,  and,  further,  that  the  condition  is 
one  belonging  to  the  developmental  period  of  life.  A  definition  some- 
thing like  the  following  would  seem  to  me  to  fairly  express  these 
desirable  points  : 

Idiocy  is  mental  feebleness  due  to  disease  or  defect  of  the  brain,  con- 
genital or  acquired  during  its  development. 

Classification. — As  regards  classifications,  they  have  been  made 
upon  a  basis  of  symptomatology,  psychology,  etiology,  craniology, 
teratology,  and,  to  a  certain  extent,  of  pathology.  But  it  seems  to  the 
writer  that  the  time  is  not  yet  come  for  an  accurately  scientific  classi- 
fication of  the  forms  of  idiocy.  It  is  much  the  best  plan  at  present  to 
adopt  an  artificial   grouping,  chiefly   clinical,  but  pathological   to   the 


768 


MENTAL  DISEASES. 


Fig.  282.—  Diplegic  idiot. 


Fig.  283. — Extreme  hydrocephalic  idiocy,  with  diplegia. 


IDIOCY. 


769 


Fig.  284. — Cretin  aged  thirteen  years  standing  beside  normal  brother  aged  four  years  (showing  dwarf- 
ing of  growth). 


Fig.  285. — Hydrocephalic  imbecile. 

49 


Fig.  286. — Idiot  with  multiple  sclerosis. 


770 


MENTAL    DISEASES. 


Fig.  287. — Microcephalic  idiocy — wild,  restless,  quar- 
relsome, perverted. 


Fig.  288.— Hydrocephalic  feeble- 
mindedness. 


Fig.  289. — Microcephalic  idiocy. 


Fig.  290.— Paraplegic  idiocy. 


IDIOCY. 


Ill 


Fig.  291.— Microcephalic  imbecile— good-natured  Fig.  292.— Good-natured  imbecile— fair 

and  a  fair  worker.  worker. 


Fig.  293.— Two  epileptic  idiots 


772  MENTAL   DISEASES. 

extent  of  our  latest  knowledge.  Almost  any  of  the  types  of  the 
divisions  here  made  use  of  may  be  congenital  or  acquired.  The  term 
idiocy  itself  is  generic,  including  as  it  does  all  degrees  of  mental 
impairment  in  early  life.  But  the  variations  in  degree  or  intensity  of 
the  mental  weakness  are  indicated  by  the  expressions  :  idiocy,  for  the 
lowest  degree  of  mental  disability  ;  imbecility,  for  a  higher  degree,  and 
feeble-mindedness,  for  the  cases  of  idiocy  in  which  the  psychic  faculties 
have  their  highest  development.  There  is  some  confusion  in  literature 
as  to  the  exact  limitation  and  application  of  these  degrees.  Sollier  has 
made  an  attempt  to  distinguish  idiocy  and  imbecility,  but  his  definition 
of  imbecility  is  not  tenable,  in  the  opinion  of  the  writer,  for  he 
describes  a  certain  small  class  of  imbeciles  as  representative  of  the 
whole  order.  It  is  to  be  remembered  that  in  each  of  these  degrees  we 
have  many  gradations,  and  the  entire  series,  from  absolute  idiocy  to  a 
normal  state,  leads  up  by  progressive  stages  through  various  types  of 
idiocy,  several  steps  of  imbecility,  and  numerous  shades  of  feeble- 
mindedness, until  the  borderland  between  the  highest  degenerate  and 
the  normal  individual  is  almost  indefinable. 

The  highest  group  includes  a  rather  well-defined  class  of  feeble- 
minded :  the  "  backward  children,"  the  enfants  arrieres  of  the  French, 
the  tardiviot  the  Italians,  and  the  Geistig-zuruckgebliebene  of  the  Germans. 
The  difficulty  is  not  so  much  in  the  delimitation  of  this  class,  as  in  the 
separation  of  the  group  of  idiots  and  imbeciles.  It  is  easy  to  make  the 
classification  on  seeing  the  cases,  but  to  convey  to  others  the  differentia- 
tion by  description  is  far  from  being  so,  because  of  the  many  features — 
physical,  motor,  and  mental — which  are  concerned  in  such  division. 
The  writer,  while  employing  the  term  idiocy  often  to  include  all  of 
these  degrees,  would  define  the  idiot  proper  as  an  individual  able  to 
give  little  or  no  care  to  his  person  ;  incapable  of  intelligent  com- 
munication, barely  able  to  express  his  material  wants,  most  awk- 
ward and  ungainly  in  his  movements,  if  he  move  at  all,  and  presenting 
marked  evidence  in  his  lack  of  expression,  apathetic  attitudes,  and  physi- 
cal stigmata  of  degeneration,  of  the  profound  stunting  of  his  mental  and 
physical  development.  On  the  other  hand,  the  imbecile  is  able  to  care 
for  his  person  and  dress,  attend  to  his  physical  wants,  comprehend 
fairly  what  is  said  to  him,  carry  out  orders  more  or  less  intelligently,  is 
often  able  to  speak  well  (though  sometimes  speech  may  be  impossible 
to  a  very  intelligent  imbecile) ;  if  not  paralyzed,  he  has  good  use  of  all 
his  muscles ;  he  is  not  destitute  of  expression,  though  the  expression 
may  vary  from  an  evil,  mischievous,  cunning  cast  of  countenance  to 
one  of  rollicking  good  nature  ;  there  are  fewer  stigmata  of  degenera- 
tion in  this  class  than  among  idiots. 

The  clinicopathological  grouping  of  the  varieties  of  idiocy  which 
the  writer  has  found  most  useful  to  him  in  his  work  at  the  Randall's 
Island  Hospital  for  Idiots  is  as  follows  : 

1.  Hydrocephalic  idiocy. 

2.  Microcephalic  idiocy. 

3.  Paralytic  idiocy. 

4.  Epileptic  idiocy. 


Fig.  294. — Epileptic  idiocy. 


Fig.  295. — Imbecile,  with  extreme  dolichocepbaly. 
(Length-breadth  index,  51.) 


Fig.  296. — Heiuiplegic  idiocy. 
(Blainville  ears.) 


Fig.  297. — Microcephalic  imbecile. 


Fig.  29H. — Idiocy  as  a  result  of  dementia  from  acute 
insanity  in  childhood. 


Fig.  299. — Epileptic  idiocy. 


773 


774  MENTAL  DISEASES. 

5.  Traumatic  idiocy. 

6.  Sensorial  idiocy. 

7.  Meningitic  idiocy. 

8.  Myxedematous  idiocy,  or  cretinism. 

9.  Amaurotic  idiocy. 
10.   Idiots  savants. 

It  is  impossible,  in  the  brief  space  allotted  this  subject,  to  discuss 
these  various  forms  of  idiocy  in  detail.  The  reader  must  be  referred 
to  special  works  and  articles  on  idiocy — to  the  general  works  of  Downs, 
Shuttleworth,  Voisin,  Sollier,  etc. — and  to  the  monographs  by  the 
writer  and  others.  Hydrocephalic,  microcephalic,  paralytic,  epileptic, 
and  traumatic  idiocy  are  readily  recognized  by  their  symptoms  or  history. 
Sensorial  idiocy  is  a  form  due  to  the  congenital  or  early  loss  of  two 
such  senses  as  sight  and  hearing.  Properly  treated,  these  patients  are 
capable  of  normal  mental  development  (Helen  Kellar  and  Laura  Bridg- 
man).  Meningitic  idiocy  can  usually  be  diagnosticated  only  by  autopsy, 
unless  the  history  or  exacerbations  in  the  course  of  the  disease  demon- 
strate its  origin.  Cretinism  is  a  rare  form  which  has  been  fully 
described  in  many  brochures  in  recent  years.  The  amaurotic  form  is 
still  rarer.  There  are  only  two  of  these  in  the  Randall's  Island 
Asylum  among  many  hundreds  of  idiots. 

The  term  idiots  savants  is  applied  to  all  such  idiots,  imbeciles,  or 
feeble-minded  as  exhibit  special  aptitudes  of  one  kind  or  another, 
always  out  of  proportion  to  their  intellectual  development  in  other 
directions,  and  often  remarkable  as  compared  with  similar  accomplish- 
ments or  faculties  in  normal  individuals. 

There  are  many  cases  of  the  kind  recorded  in  literature,  and  it  is 
not  at  all  uncommon  to  hear  of  idiots  in  our  newspapers  and  museums 
who  are  exhibited  as  musical  prodigies,  "  calculating  boys,"  and  the 
like.  Beyond  the  fact  of  the  existence  of  such  curiosities,  and  the  record 
of  their  deeds,  there  has  been  little  or  nothing  written  in  explanation  of 
these  phenomena.  The  psychology  of  the  condition  is  exceedingly 
obscure  ;  and  even  were  the  psychological  processes  which  underlie  special 
aptitudes  understood,  there  would  still  remain  the  mystery  of  the  mani- 
festation of  particular  talents  or  faculties  in  minds  otherwise  blank  or 
defective. 

The  aptitudes  may  be  summarized  as  follows  : 

Arithmetical  faculty,  musical  faculty,  special  memories,  imitative 
faculty,  modeling  faculty,  delineative  faculty,  faculty  for  painting,  apti- 
tude for  games  (draughts,  etc.),  aptitude  for  buffoonery.  (See  article  by 
author  on  "  Idiots  Savants  "  in  Appleton's  "  Popular  Science  Monthly," 
December,  1896,  in  which  a  history  of  some  remarkable  examples  is 
given.     See  also  page  777  of  this  book.) 

General  Etiology. — There  are  nearly  twice  as  many  male  as  female 
idiots.  In  idiocy  due  to  prolonged  or  difficult  labor,  this  disproportion 
is  even  larger  (three  males  to  one  female) — a  fact  to  be  explained  probably 
by  the  larger  size  of  the  male  infant.  The  causes  of  idiocy  may  be  classi- 
fied as  follows  : 


IDIOCY. 


775 


Fig.  300.—  Paraplegic  idiocy. 


Fig.  301. — Idiocy  after  acute  insanity  of  childhood. 
Peculiar  tic  of  fingers. 


Fig.  302. — Two  imbeciles,  one  epileptic  and  one  of  unknown  origin  (both  homosexual  perverts). 


776 


MENTAL  DISEASES. 


Hereditary  transformation  of  nervous  and  mental  diseases. 
Pathological  heredity  in  the  form  of  vitiating  diseases  or  habits  (tu- 
Degenerative  /      berculosis,  rheumatism,  gout,  herpetism,  syphilis,  alcoholism,  etc. ). 
Sociological  factors  (extreme  youth  of   parents,    extreme  age  of 
parents,  disproportionate  age  of  parents,  consanguinity). 


Adventitious 


Maternal 


Trauma,  shock,  fright,  diseases,  maternal 
impressions. 


Gestational 


Parturi- 
tional 


tji  f-  1      f  Syphilis,  heart  disease,  arteritis,  morbid 

-ry  e  f      \       processes  in  the  brain  and  meninges, 
^isomers  ^      twia  pregnancy- 

f  Difficult  labor,  primogeniture,  premature  birth, 
<  asphyxia  at  birth,  instrumental  injuries,  pressure 
J      on  the  cord. 


[  Convulsions,  cerebral  diseases,  trauma  to  the  head, 
Postnatal   <      febrile  diseases,    mental    shock,   sunstroke,    over- 
(     pressure  at  school. 


The  relations  of  heredity  to  idiocy  are  much  the  same  as  those  of 
heredity  to  the  psychoses  described  in  the  chapter  on  General  Etiology  of 
Insanity.  The  statistics  available  (such  as  those  of  Shuttleworth  and 
Beach,  Langdon  Down,  Kerlin,  and  Piper)  seem  to  show  neurotic  in- 
heritance in  about  forty  to  fifty  per  cent,  of  idiots.  The  stigmata  of 
degeneration,  which  are  so  marked  in  idiocy,  are  described  in  an  earlier 
chapter.  As  regards  tuberculosis  and  scrofula  in  the  parents,  the  per- 
centages of  these  authors  vary  from  fifteen  to  thirty  per  cent.  Alco- 
holism takes  a  high  place  among  the  causes  of  progressive  hereditary 
degeneration  (nine  to  sixteen  per  cent.).  The  writer  has  found  that 
hereditary  syphilis  is  a  comparatively  rarer  cause  of  idiocy  than  many 
would  suppose,  and  this  is  supported  by  the  statistics  of  the  authors 
named  above  (one  to  two  per  cent.).  As  regards  consanguinity,  the  sta- 
tistics show  that  the  proportion  of  idiotic  offspring  of  cousins  to  the 
number  of  idiots  is  very  slightly  in  excess  of  the  number  of  consanguin- 
eous marriages  to  marriages  in  general. 

Gestational  causes  vary,  according  to  the  statistics,  from  eleven  to 
thirty  per  cent.  Parturitional  factors  (meningeal  hemorrhage  from 
prolonged  labor,  asphyxia  at  birth,  premature  birth,  pressure  on  the 
cord,  forceps  injuries,  etc.)  are  active  in  about  eighteen  per  cent.  It 
may  be  said  that  forceps  injuries  are  far  less  dangerous  to  the  child  than 
tedious  labor.  Among  adventitious  causes  infantile  convulsions  occupy 
a  preeminent  position  (over  25  per  cent.).  But  we  must  remember 
that  the  convulsions  may  act  as  a  real  cause,  by  inducing  meningeal 
hemorrhage ;  or  convulsions  may  be  merely  an  associated  symptom  of 
a  meningeal  hemorrhage  or  other  pathological  condition  due  to  some 
other  common  factor.  Cerebral  diseases  (meningitis,  hydrocephalus, 
hemorrhage,  thrombosis,  embolism,  tumor,  and  abscess)  follow  infantile 
convulsions  in  the  statistical  table  of  causes  (eight  to  nine  per  cent.). 

Acute  febrile  diseases  induce  idiocy  in  some  six  per  cent,  of  cases. 


IDIOCY.  777 

These  diseases  are  scarlet  fever,  measles,  whooping-cough,  typhoid 
fever,  small-pox,  and  diphtheria.  How  they  act  is  not  yet  known. 
Sometimes  it  is  through  meningeal  hemorrhage  induced  by  the  convul- 
sions so  common  at  the  onset  or  during  the  course  of  these  maladies. 
Possibly  at  other  times  it  is  through  an  infectious  encephalitis,  or 
microbic  embolism  or  thrombosis.  Trauma  to  the  head,  mental  shock, 
sunstroke,  and  "cramming"  at  school  have  a  small,  yet  appreciable, 
share  in  the  production  of  idiocy  (probably  two  to  five  per  cent,  alto- 
gether). The  author  has  found,  in  his  own  experience,  that  insanity  in 
children  is  an  occasional  cause  of  idiocy.  In  the  adult  such  mental 
enfeeblement  after  insanity  is  a  secondary  dementia,  but  in  the  growing 
child  this  secondary  dementia  is  preferably  termed  idiocy. 

General  Symptomatology. — Since  idiocy,  as  well  as  its  varying 
degrees  of  imbecility  and  feeble-mindedness,  depends  upon  some  sort 
of  congenital  or  acquired  defect  or  disease  of  the  brain  interfering 
with  its  normal  evolution,  it  is  clear  that  the  cerebral  functions  may 
be  all  of  them  more  or  less  involved,  and  that  no  particular  psychic 
faculty  can  be  selected  as  the  one  whose  disorder  retards  or  influences 
the  development  of  the  other  faculties.  Seguin  is,  therefore,  hardly 
correct  in  stating  that  the  condition  of  the  mental  faculties  in  idiots  is 
normal,  though  diminished,  and  that  merely  the  will  is  lacking  to 
give  them  proper  direction.  Sollier  has  given  us  one  of  the  best  and 
latest  studies  of  the  psychology  of  idiocy.1  Following  Ribot  and 
others,  he  maintains  that  the  slow  development  of  the  cerebral  facul- 
ties is  due  to  want  of  attention  ;  that  spontaneous  attention  is  caused  by 
affective  states  brought  into  action  by  sensations,  and  that  those  young 
children  are  the  most  attentive  whose  nervous  systems  are  most  easily 
stimulated.  Hence  the  faculty  of  attention  is  closely  related  to  the 
activity  of  the  sensations.  The  greater  the  power  of  attention,  the 
more  intelligent  does  the  individual  become.  In  idiocy,  owing  to  the 
diminution  or  loss  of  the  power  of  attention,  the  perceptions  aroused  by 
sensations  are  more  or  less  indefinite,  and  the  resultant  idea  likewise 
ill-defined.  Sensations  become  more  numerous  as  the  organism  develops, 
and  the  lack  of  ideas  and  recognitions  becomes  more  noticeable. 

Following  somewhat  the  natural  order  of  such  examination,  with  the 
excellent  work  of  Sollier2  as  a  guide,  we  first  take  up  the  senses,  those 
avenues  which  lead  to  psychological  development. 

Sight. — Between  seven  and  eight  per  cent,  of  idiots  are  congenitally 
blind.  It  is  necessary  to  determine  whether  the  blindness  is  due  to 
defect  of  the  visual  apparatus  or  to  lack  of  attention.  Blindness  does 
not  preclude  the  possibility  of  education,  for  some  idiots  with  defect 
of  this  sense  may  be  educated  to  a  moderate  degree.  When  idiots  can 
look,  without  in  reality  seeing,  the  apparent  blindness  is  due  to  a  com- 
plete absence  of  attention.  In  idiots  less  affected,  a  greater  variety  of 
objects  will  attract  their  attention.  In  the  higher  grades  of  idiocy 
(imbecility  and  feeble-mindedness)  vision  may  be  as  good  as  in  normal 

1  "Psychologie  de  l'idiot  et  de  l'imbecile,"  Paris,  1891. 

2  The  author,  while  differing  from  Sollier  materially  in  some  of  his  conclusions,  is 
indebted  to  his  work  for  many  of  the  details  of  the  psychological  symptoms  of  idiocy. 


778  MENTAL   DISEASES. 

man.  But  many  present  certain  visual  and  ocular  defects,  such  as 
hypermetropia,  defective  color-vision,  strabismus,  nystagmus,  congenital 
cataract,  inequality  of  the  pupils,  microphthalmos,  and  the  like.  In 
hemiplegic  idiocy  or  imbecility  we  may  find  hemianopia.  But  the  de- 
termination of  the  acuity  of  vision  is  difficult  in  this  class  of  individuals. 
The  perception  of  different  colors  is  often  possible  in  the  milder  degrees 
of  idiocy.  Good  binocular  vision  is  uncommon  in  idiots.  The  normal 
child  takes  pleasure  in  the  sight  of  objects  as  early  as  the  eleventh  day, 
the  eyes  are  normally  coordinated  by  the  end  of  the  second  month,  and 
he  begins  to  distinguish  colors  correctly  at  about  the  age  of  two  years. 

Hearing1. — There  is  a  somewhat  analogous  condition  of  the  organs 
of  hearing.  It  is  not  always  easy  to  determine  whether  an  idiot  is  deaf 
from  defect  in  the  auditory  apparatus  or  only  sensorially  deaf.  Idiocy 
of  mild  degree  is  not  infrequently  induced  by  deprivation  of  this  sense. 
In  the  higher  grades  of  idiocy  hearing  is  nearly  always  normal.  Deaf- 
mutism  can  not  be  considered  as  common.  The  normal  child  hears  on 
the  fourth  day,  and  is  pleased  with  music  in  the  second  month. 

Taste. — This  sense  is  frequently  affected.  Gluttony  is  a  marked 
feature  in  idiocy.  It  is  common  for  idiots  to  eat  without  mastication  ; 
many  present  a  precocious  taste  for  alcohol.  This  is  especially  true 
of  the  higher  grades.  A  difficulty  in  distinguishing  the  simple  tastes 
(salt,  sweet,  bitter,  and  sour)  is  not  infrequently  met  with  in  the  milder 
types,  as  well  as  in  those  with  great  mental  impairment.  Inversions 
and  perversions  of  taste  are  observed.  The  normal  child  evinces  a 
sensibility  to  taste  at  the  end  of  the  first  week. 

Smell. — In  the  normal  child  strong-smelling  substances  produce 
mimetic  movements  on  the  day  of  birth.  In  idiocy  the  sense  may  be 
much  impaired,  perverted,  or  absent. 

Tactile  Pain  and  Muscular  Sensibility. — As  a  rule,  sensibility 
to  touch  and  pain  is  uniformly  diminished  in  idiocy  of  all  degrees, 
mostly  through  lack  of  attention.  There  may  be  complete  anesthesia 
and  analgesia,  particularly  in  the  lower  grades.  On  the  other  hand, 
there  are  cases  in  which  the  sense  of  touch  may  be  educated  to  a  high 
degree  of  delicacy.  It  is  almost  impossible  to  study  the  muscular  sense 
in  idiots,  but  it  is  apt  to  be  impaired  in  proportion  to  the  other  senses. 
The  normal  child  starts  at  gentle  touches  on  the  second  and  third  days, 
and  manifests  muscular  sense  as  early  as  the  eighth  week. 

Thermic  Sensibility. — What  has  been  said  of  touch  and  pain 
applies  likewise  to  the  temperature  sense.  But  their  vasomotor 
systems  are  susceptible  to  the  influences  of  cold  and  exposure,  and  their 
resistance  to  external  influences  and  diseases  is  such  that  many  of  them 
die  of  pulmonary  affections.  Some  become  more  stupid  in  cold  weather 
and  brighter  in  warm  weather,  while  an  elevation  of  bodily  tempera- 
ture (fever)  is  accompanied  by  evidences  of  more  active  cerebration. 

Morbid  Movements. — A  small  number  of  idiots  exhibit  no  motility 
at  all,  but  remain  perfectly  inert.  But  the  majority  are  apt  to  be  in 
constant  motion.  These  movements  tend  to  take  on  a  rhythmic  and 
automatic  character.  I  do  not  here  refer  to  such  morbid  movements  as 
epilepsy,    athetosis,  associated    movements,    ataxia,    and    chorea,   often 


idiocy.  779 

present  in  paralytie  idiocy ;  nor  to  tremor,  found  in  sclerotic  cases  ;  but 
to  a  group  of  automatic  or  impulsive  movements. 

These  forms  of  movements  are  among  the  most  common  and  striking 
symptoms  immediately  noticed  in  going  through  an  institution  for  idiots. 
A  very  large  proportion  of  the  inmates  are  observed  to  be  in  continual 
motion.  As  a  rule,  the  most  frequent  rhythmic  movement  is  an 
anteroposterior  oscillation.  The  patient,  in  a  sitting  attitude,  sways 
his  body  slowly  or  rapidly  backward  and  forward.  Sometimes  the 
oscillation  is  from  side  to  side.  Occasionally  the  hands  and  fingers  are 
rapidly  or  slowly  flexed  and  extended,  and  brought  up  to  the  face  in 
movements  similar  to  those  in  athetosis,  but  differing  from  them  in  that 
they  are  entirely  subject  to  the  will,  just  as  are  the  oscillations  alluded 
to.  Walking  to  and  fro,  rotating,  dancing,  and  so  on,  are  more  elab- 
orate forms  of  the  same  kind  of  impulsive  movement.  Similar  move- 
ments occur  in  the  insane,  as  is  well  known,  and  particularly  in 
conditions  of  greatly  enfeebled  mind,  such  as  secondary  dementia. 
They  are  spontaneous  movements,  seeming  to  have  no  relation  to  any 
stimulation  of  the  brain  giving  rise  to  a  motor  expression.  Generally 
the  movements  cease  for  a  time  when  any  sensory  impression,  such  as 
the  appearance  of  a  stranger  in  the  room  or  being  spoken  to,  temporarily 
alters  the  feeble  current  of  thought  or  excites  the  mental  blankness 
which  has  given  rise  to  the  automatic  movement.  Children  and  young 
animals  are  full  of  spontaneous  movements,  undoubtedly  due  to  impres- 
sions received  at  some  time  during  their  lives,  or,  it  may  be,  impres- 
sions inherited ;  and,  while  these  spontaneous  movements  of  children 
are  undoubtedly  similar  in  their  nature  to  the  automatic  movements  of 
dements  and  idiots  just  described,  they  do  not  often  present  the 
rhythmic  character  of  the  latter.  It  is  probable  that  in  the  feeble 
mind,  upon  which  nerve  stimuli  seldom  make  an  impression,  the  simple 
old  motor  expressions  are  retained,  repeated,  and  become  habitual  or 
automatic.  Automatism  of  movement  is  thus  a  sign  of  little  aptitude 
or  impressionability,  so  far  as  fresh  mental  stimulation  is  concerned. 
In  the  idiot  the  impulsive  rhythmic  movements  just  described  may  be 
regarded  as  the  habitual  motor  expression  of  the  simplest  and  oldest 
stimuli ;  whereas,  in  the  secondary  dement,  the  analogous  automatic 
movements  are  to  be  looked  upon  as  reversions  to  the  spontaneous 
movements  of  infancy.  The  smiles  and  grimaces  of  idiots  and  imbeciles 
belong  to  the  same  category  of  infantile  spontaneous  motor  expressions. 

There  is  probably  a  certain  amount  of  pleasure  in  the  movements 
in  many  cases,  as  sometimes  they  manifest  displeasure  if  prevented 
from  executing  them.  There  is  nearly  always  a  difficulty  out  of  pro- 
portion to  the  intellectual  development  for  idiots  to  perform  associated 
movements  with  a  definite  object.  They  may  be  able  to  talk  and  read, 
and  even  write,  yet  be  unable  to  dress  themselves.  This  is  often  a  fault 
remediable  by  education,  according  to  Seguin. 

Right-handedness  and  Left-handedness. — Some  twelve  per  cent, 
of  all  children,  idiot  and  normal,  are  left-handed  ;  but  while  eighty-eight 
per  cent,  of  normal  children  are  right-handed,  only  seventy-two  per  cent, 
of  idiots  use  their  right  hand  in  preference,  the   remaining   sixteen  per 


780  MENTAL   DISEASES. 

cent,  being  ambidextrous.  This  peculiarity  is  said  to  be  present  also 
among  criminals. 

Voluntary  Movements. — Many  idiots  do  not  learn  to  walk  at  all, 
either  because  of  general  debility,  inability  to  learn,  or  paralysis.  In 
such  as  do  acquire  the  ability  to  walk  there  is  great  retardation  in  its 
acquisition.  This  is  also  true  of  other  uses  of  the  voluntary  muscles 
for  the  common  acts  of  daily  life,  such  as  carrying  food  to  the  mouth, 
and  so  on.     They  are  either  never  learned  or  they  are  acquired  late. 

Organic  Sensations. — The  keenness  of  visceral  sensibility  is 
more  or  less  diminished  in  all  idiots.  The  sensations  of  hunger  and 
thirst  are  lessened,  though  only  very  rarely  absent.  The  feeling  of 
satiety  after  a  hearty  meal  is  seldom  felt  by  them  ;  so  that  if  left  to 
themselves,  they  would  eat  on  indefinitely.  The  necessity  of  defecation 
and  micturition  is  not  perceived  at  all  by  profound  idiots.  In  the 
lower  and  middle  grades  of  idiocy  it  is  often  difficult  to  diagnosticate 
visceral  disease,  owing  to  the  bluntness  of  somatic  sensations,  and  they 
may  die  without  giving  any  appreciable  symptoms.  This  masking  of 
disease  in  idiocy  is  quite  analogous  to  the  masking  of  disease  in  various 
insanities.  The  feeble-minded  and  imbeciles  not  infrequently  mislead 
the  physician  by  exaggeration,  concealment,  or  falsehood. 

Attention. — The  lack  of  the  faculty  of  attention  is  one  of  the 
chief  characteristics  of  idiocy.  Naturally,  it  varies  in  degree  from 
complete  nullity  to  a  simple  diminution  of  the  faculty,  but  it  is  always 
lessened.  The  fundamental  elements  of  the  faculty  are  deficient. 
These  fundamental  elements  are  :  The  integrity  of  sensory  impressions 
delivered  to  the  brain  ;  an  emotional  state  of  pleasure,  pain,  or  interest 
in  such  sensations ;  motor  expressions  in  the  eyes,  face,  limbs,  or  body 
of  the  impressions  received.  There  are  two  forms  of  attention,  accord- 
ing to  Ribot  and  Sollier,  one  of  which  is  natural  or  spontaneous,  and 
the  other  voluntary,  established  by  education.  The  latter  can  not 
exist  without  the  former. 

There  are  two  qualities  in  attention  that  are  of  importance — viz., 
intensity  and  duration. 

Thus,  attention  is  impaired  in  idiocy  by  the  defective  senses,  which 
convey  to  the  brain  feeble  impressions.  The  second  element,  the  affec- 
tive state,  is  notably  lacking  in  idiots.  The  motor  factor  of  attention 
is  deranged  in  idiocy  in  a  great  variety  of  ways  (general  weakness, 
paralysis,  contracture,  epilepsy,  chorea,  ataxia,  automatic  and  impul- 
sive movements,  and  the  like).  The  intensity  and  duration  of  attention 
are  restricted  to  the  last  degree  in  this  class  of  individuals. 

The  intelligence  and  the  possibility  of  education  depend  directly 
upon  the  power  of  the  faculty  of  both  spontaneous  and  voluntary  at- 
tention. It  is  probable  that  the  faculty  is  localized  chiefly  in  the  frontal 
lobes  of  the  brain.  Ferrier  considers  it  proportionate  to  the  develop- 
ment of  these  lobes,  and  some  very  convincing  experiments  recently 
published  by  Bianchi  make  it  quite  certain  that  the  frontal  lobes  are  the 
seat  of  this  faculty.  In  idiots  great  lack  of  attention  is  coincident  with 
diminutive  size  of  the  frontal  lobes. 

In  the  low  grades  of  idiocy  spontaneous  attention   is   almost  null, 


IDIOCY.  781 

and  education  is  impossible.  The  higher  the  degree  of  idiocy,  the 
greater  the  degree  of  spontaneous  attention  presented,  which  maybe  so 
appealed  to  as  to  develop  it  into  voluntary  attention,  with  intellectual 
progress  as  a  consequence.  With  idiots,  as  with  the  lower  animals,  at- 
tention is  always  connected  with  the  sense  most  perfectly  developed, 
which,  in  the  former,  is  that  of  sight.  The  attention  of  idiots  is  most 
easily  aroused  through  the  eyes.  Exercises  of  the  attention  may  thus 
be  employed  in  the  diagnosis  of  states  of  intellectual  weakness.  We 
find  idiots  without  attention  absolutely  ineducable,  leading  a  vegetative 
existence;  others,  again,  exhibiting  both  spontaneous  and  voluntary 
attention,  but  in  flashes,  as  it  were,  of  brief  duration  and  faint  in  na- 
ture ;  and  still  others  more  or  less  capable  of  prolonged  and  habitual 
attention.  It  is  only  in  the  last-named  group  of  individuals  that  edu- 
cation is  to  any  considerable  degree  feasible.  The  education  appeals 
in  some  to  the  simplest  sentiments  only  (such  as  curiosity,  selfish- 
ness, the  desire  of  reward),  in  others  attention  is  aroused  by  appeals  to 
a  higher  affective  order  (such  as  interest,  ambition,  and  emulation),  and 
in  still  others  attention  may  be  aroused  and  sustained  by  habit. 

Since  the  power  of  attention  directed  to  external  events  is  so  feebly 
developed  in  idiots,  it  is  not  surprising  that  attention  to  internal  happen- 
ings, or  reflection,  should  be  totally  absent  in  all  grades  of  idiocy. 

Kibot  regards  voluntary  attention  as  habitual  and  disciplined  spon- 
taneous attention,  as  an  adaptation  to  the  conditions  of  a  higher  social 
life,  as  a  sociological  phenomenon.  When  the  development  of  voluntary 
attention  is  rudimentary,  and  the  resulting  intellectual  defect  is  marked, 
as  in  the  lower  grades  of  idiocy,  there  are  no  serious  consequences  from 
the  sociological  point  of  view.  Sollier  calls  the  idiot  extra-social,  and 
makes  the  imbecile  quite  distinct  as  anti-social,  claiming  that  in  the 
latter  there  is  an  undefined  amount  of  voluntary  attention,  combined 
with  a  relative,  though  perverted,  intelligence,  which  two  factors  render 
him  often  a  dangerous  member  of  society.  He  speaks  of  the  instability 
of  the  attention  of  the  imbecile.  At  one  moment  it  may  be  faint,  at 
another  intense  as  in  normal  man.  He  passes  from  one  subject  to  an- 
other with  the  greatest  ease,  a  characteristic  which  may  even  be  observed 
in  his  infancy.  Serious  matters  must  be  continually  repeated  to  him  to 
make  him  understand.  He  grasps  the  first  part  of  a  sentence,  and 
forms  his  ideas  from  that,  without  waiting  for  the  sentence  to  be  com- 
pleted. He  frequently  interrupts,  and  there  is  no  time  to  answer  one 
question  before  another  is  put,  Sollier  further  goes  on  to  say  that  this 
instability  of  the  attention  for  external  objects  or  ideas  is  seen  also  in 
the  acts  of  the  imbecile,  who  is  incapable  of  intelligent  labor,  and  accom- 
plishes his  tasks,  when  uniform,  by  a  certain  kind  of  automatism,  with- 
out due  appreciation  of  the  object  of  his  work.  When  the  object  is 
understood,  the  imbecile  believes  he  can  attain  it  immediately,  and, 
seeing  the  first  step  only,  is  prevented  by  failure  of  attention  from  properly 
completing  the  work  or  doing  it  at  all.  He  seems  to  forget  that  he  has 
begun,  and  as  a  consequence,  unless  watched,  may  spoil  whatever  he  at- 
tempts. Other  imbeciles  refuse  to  work,  but  make  themselves  very  busy 
and  important  in  watching  and  supervising  the  occupations  of  others. 


782  MENTAL   DISEASES. 

Sollier  calls  them  vagabonds.  They  wander  away  not  knowing  where, 
marching  straight  before  them,  with  indifference  to  the  welfare  of  the 
friends  or  relatives  they  desert ;  traveling  by  night  and  hiding  by  day ; 
undisciplined,  indolent,  and  mischievous. 

This  attempt  to  separate  idiots  and  imbeciles  into  two  distinct  classes 
of  extrasocial  and  antisocial  is,  to  my  mind,  not  justifiable.  Sollier 
has  here  described  a  certain  class  of  imbeciles  only,  and  the  description 
is  very  true  to  nature,  but  it  is  only  a  group  which  does  not  merit  an 
especial  classification.  As  regards  attention,  we  should  still  hold  to  the 
terms  idiocy,  imbecility,  and  feeble-mindedness,  as  representing  degrees 
of  lack  of  attention,  from  complete  or  almost  complete  absence  to  mere 
diminution  of  the  faculty.  The  adult  imbecile,  in  the  middle  grade, 
would  have  the  varying  and  imperfect  attention  of  a  backward  child, 
and  his  ideas,  speech,  and  conduct  would  vary  with  his  temperament, 
with  his  docility  or  perversity  ;  in  short,  with  the  innate  differences  of 
character  and  individuality,  which  may  be  as  manifest  in  imbeciles  as 
in  normal  children.  Imbeciles  may  and  do  become  vagabonds,  un- 
certain, mischievous,  indolent,  antisocial ;  but  they  may,  on  the  other 
hand,  be  good-natured,  trusty,  docile,  industrious.  Many  of  them,  too, 
may  show  special  aptitudes  in  certain  directions.  As  to  education,  the 
difficulties  are  that  in  some  it  is  hard  to  attract  the  attention,  and  in 
others  to  maintain  it. 

Reflection. — The  internal  form  of  attention  (reflection  of  Ribot), 
in  which  images  and  ideas  constitute  the  subject-matter,  is  quite  defi- 
cient in  the  lower  grades  of  idiocy,  but  is  present  in  imbecility  and 
feeble-mindedness  in  varying  degrees.  It  is  never  perfectly  developed, 
as  in  normal  man. 

Preoccupation. — This  is  absent  in  profound  idiocy  and  feeble  in 
the  higher  grades.  A  small  proportion  of  imbeciles  are  capable  of 
preoccupation,  but  of  an  indefinite  nature,  and  sometimes  taking  on  the 
character  of  a  fixed  idea.  Often  their  interest  is  not  aroused  so  much 
by  what  benefits  and  interests  mankind  in  general  as  by  bad  actions, 
criminal  or  egoistic  sentiments  that  attract  their  attention  and  arouse 
reflection  and  preoccupation  which  may  result  in  felony  or  crime. 
Many  are  too  selfish  to  care  for  the  troubles  of  others,  and  too  stupid 
to  have  preoccupations  purely  intellectual. 

Instincts. — The  instincts  in  idiocy  are  generally  defective.  The 
defect  may  be  imperfection  of  development  or  an  actual  derangement 
or  perversion.  The  instinct  of  hunger  is  present  in  almost  all  grades 
of  idiocy,  and  is  so  little  inhibited  that  it  is  often  pushed  to  the  extent 
of  gluttony.  The  instinct  of  self-preservation  is  impaired  in  nearly 
all,  absent  in  profound  idiocy,  ungoverned  by  proper  judgment  in  the 
milder  forms.  In  some  there  is  no  sense  of  fear,  and  self-injury  is 
possible.  In  others  there  is  a  comprehension  of  danger  and  an  avoid- 
ance of  it,  or  possibly  an  overweening  egoism  which  may  lead  to  a 
belief  in  their  power  to  overcome  it.  Suicide  occurs  in  imbeciles  and 
feeble-minded,  sometimes  without  determinable  cause,  sometimes  as  a 
result  of  morbid  impulse. 

Sleep  is  good  among  all  classes  of  idiots,  while  in  the  lower  grades 


idiocy.  783 

it  may  be  both  profound  and  excessive.     Whether  they  dream  or  not 
depends  solely  upon  the  degree  of  mental  development. 

The  desire  and  need  of  voluntary  muscular  movement  varies  with 
the  scale  of  intelligence,  being  absent  in  the  profounder  degrees  of 
idiocy,  and  approximating  the  normal  the  higher  the  psychic  develop- 
ment. The  automatic  and  impulsive  movements  in  some  may  represent 
a  fulfilment  of  the  normal  need,  and  the  extreme  restlessness  of  others 
is  surely  a  perversion  of  the  natural  desire. 

The  sexual  instinct  may  be  absent,  impaired,  exaggerated,  or  per- 
verted. It  is  seldom  normal.  Idiots  of  all  degrees  present  many  de- 
generative stigmata  as  regards  the  genital  organs,  more  numerous  in 
direct  proportion  to  the  mental  impairment.  Among  these  anomalies 
are  :  cryptorchismus,  unilateral  or  bilateral  microrchidia,  spurious  her- 
maphroditism, insufficient  development  of  the  entire  genital  apparatus, 
hypospadias  or  epispadias  ;  defect,  torsion,  or  great  volume  of  the 
prepuce  ;  median  fissure  of  the  scrotum,  imperforate  meatus,  abnor- 
mally large  or  small  labia,  excessive  development  of  the  clitoris, 
hypertrophied  labia  minora,  pigmentation  of  the  labia  minora,  imper- 
forate vulva,  atresia  of  or  double  vagina,  and  uterus  bicornis. 
Puberty  is  often  retarded,  but  occasionally  is  early  ;  often  it  is  normal. 
Masturbation  is  exceedingly  common  among  all  classes  of  idiots  of  both 
sexes.  In  the  profound  degrees  it  is  automatic  ;  in  the  higher  it  is 
purposive.  Onanism  a  deux  and  sodomy  are  frequently  discovered 
among  imbeciles  and  feeble-minded,  and  sexual  psychopathies  of  the 
most  shocking  nature  are  not  uncommonly  manifested  in  some  because 
of  the  combination  of  the  strong  sexual  instinct  and  absence  of  moral 
sensibility. 

The  instinct  of  imitation,  which  is  a  low  form  of  instinct,  and  strong 
in  children  and  many  lower  animals,  is  one  to  which  idiots  are  very 
susceptible.  It  is  usually  a  purely  instinctive  or  passive  imitation, 
seldom  an  intellectual  or  active  imitation.  Its  intensity  depends  much, 
however,  upon  the  scale  of  intelligence  to  which  the  idiot  rises.  It  is 
very  apt  to  be  shown  in  the  form  which  is  concerned  with  moral  conta- 
gion ;  so  that  the  acts  and  language  of  the  vicious,  mischievous,  coarse, 
and  vulgar  are  most  willingly  imitated.  Simulation  is  very  common 
among  the  more  intelligent  classes  of  idiots. 

Special  Aptitudes. — In  the  so-called  idiots  savants  we  note  the  de- 
velopment of  special  aptitudes,  occasionally  remarkable,  more  often 
only  noteworthy  in  contrast  to  the  general  mental  vacuity.  These  apti- 
tudes are  usually  in  the  direction  of  music,  mathematics,  the  mechanical 
arts,  building,  wood-carving,  drawing,  painting,  memory  for  facts  or 
dates,  playing  games,  and  of  a  low  order  of  wit  or  drollery.  The  occa- 
sional preeminence  of  some  particular  faculty,  where  all  other  traits  are 
defective,  would  almost  lead  one  to  believe  in  a  heterotopia  of  gray 
matter  in  some  special  locality.  Music,  the  most  sensual  of  the  arts, 
seems  to  appeal  especially  to  this  class  of  individuals.  Often  the 
rhythm  of  it  seems  to  influence  the  rhythm  of  their  automatic  move- 
ments, or  it  soothes  their  restlessness  or  stops  their  cries.  Sometimes 
unteachable  idiots  are  able  to  retain,  recall,  and  hum  a  moderately  diffi- 


784  MENTAL    DISEASES. 

cult  tune,  while  higher  grades  may  learn  to  play  instruments  by  earr 
though  not  by  note.  Next  to  aptitude  for  music,  that  for  mental  arith- 
metic is  often  surprising.  There  are  also  occasional  instances  of  the 
other  talents  just  mentioned,  and  doubtless  the  court  fools  of  the  past, 
with  their  mischievous  pranks  and  quaint  remarks,  were  recruited  to  a 
great  extent  from  the  imbecile  class. 

Play. — There  is  a  lack  in  all  classes  of  idiots,  and  in  direct  propor- 
tion to  the  degree  of  mental  defect,  of  that  "  superfluous  activity  which 
is  expended  in  the  form  of  play."  The  activity  and  attention  of  normal 
children  are  mainly  developed  through  play.  This  avenue  of  education 
is,  unfortunately  to  a  considerable  degree,  closed  in  idiocy.  The  lower 
grades,  if  they  manifest  a  tendency  to  play  at  all,  do  so  in  a  rudimentary 
and  solitary  way,  and  in  adolescence  still  cling  to  the  simple  games  of 
infancy.  With  others,  higher  in  the  scale  of  intelligence,  there  is  still 
defect  of  the  play  instinct,  and  a  proclivity  often  to  prefer  games  in 
which  noisiness,  destructiveness,  and  other  evidence  of  rather  brutal 
traits  are  paramount.  Sometimes  these  games  are  carried  on  good- 
naturedly  ;  at  others,  selfishness,  irritability,  quarrelsomeness,  and  a 
more  or  less  ungovernable  nature  are  evinced. 

Civility  and  politeness  may  be  taught  to  many,  but  naturally  with 
difficulty  to  the  lower  grades  and  to  such  individuals  of  the  higher  as 
are  hard  to  train  in  other  directions,  because  of  innate  vices  of  tempera- 
ment and  character. 

Destructiveness,  a  propensity  even  in  normal  children  at  an  early 
age,  is  an  especial  attribute  of  all  classes  of  idiots.  In  those  of  low 
degree  it  is  automatic  and  possibly  a  rudimentary  form  of  superfluous 
activity  (play),  but  in  some  individuals  of  the  superior  grades  there 
seems,  at  times,  to  be  a  vicious  satisfaction  in  inflicting  damage  or 
injury,  which  may  even  lead  to  the  manifestation  of  homicidal  proclivi- 
ties or  a  tendency  to  arson  (pyromania).  Self-mutilation  or  injury  may 
be  a  result  of  the  love  of  destruction  in  the  pro  founder  degrees  of  idiocy. 

Sentiments. — In  the  lowest  forms  of  idiocy  the  sentiments  and 
sensations  are  rudimentary,  or  may  be  altogether  absent.  As  a  rule,  one 
may  discover  various  degrees  of  pleasure  or  pain,  affection,  pity,  fear, 
social  proclivities,  love  of  property,  regard  for  rights  and  duty,  obedi- 
ence, shame,  esthetic  feelings,  curiosity,  and  the  like. 

Pleasure  and  pain  are  indefinite  or  absent  sensations  in  idiots,  felt 
to  a  greater  extent  by  imbeciles,  and  well  marked  in  the  feeble-minded. 
Joy,  sadness,  and  anger  are  usually  aroused  by  physical  sensations. 
The  self-mutilation  of  some  idiots  points  to  an  absence  of  the  pain 
sense,  and  idiot  women  have  been  known  to  bear  children  without  ex- 
periencing the  pains  of  labor.  Idiots  often  cry  out  suddenly,  burst  out 
laughing,  or  throw  themselves  about,  which  is  probably  explicable  by 
variations  of  perception  in  the  somesthetic  sense.  Moral  pain  or 
remorse,  usually  wanting,  is  sometimes  developed  to  a  slight  extent.  It 
is  not  often  that  these  defectives  weep,  and  if  they  cry,  it  is  but  for  some 
momentary  pain  or  deprivation.  They  live  in  the  present  only,  and  do 
not  concern  themselves  about  the  past  or  future.  In  the  higher  grades 
it  is  physical,  seldom  moral,  pain  that  is  taken  note  of.     Pleasure  is 


IDIOCY.  785 

as  little  experienced  as  pain  in  the  lower  degrees,  and  laughter  is  as 
infrequent  as  crying.  Pleasure  is  expressed  by  imbeciles  and  the 
feeble-minded  by  laughter,  clapping  the  hands,  or  cries,  though 
laughter,  even  with  these,  is  uncommon.  There  are,  however,  certain 
imbeciles  that  always  have  a  good-natured  smile,  and  laugh  readily  and 
excessively  over  nothing.  Frequently  the  laughter  is  a  true  automatic 
movement,  as  infantile  spontaneous  motor  expression. 

Affection  is  a  sentiment  not  uncommon  in  idiocy,  though  it  varies 
with  the  degree,  being  often  rudimentary,  vague,  indefinite,  and  proba- 
bly inspired  rather  by  the  ministration  to  his  wants  than  by  the  care- 
taker. It  is  found  that  nearly  all  forms,  except  the  lowest,  appreciate 
kindness  and  patience,  and  are  repulsed  and  made  unmanageable  by 
brusqueness  or  cruelty.  With  certain  imbeciles  and  feeble-minded, 
where  the  moral  sense  is  not  too  much  obtunded,  true  affection  for  indi- 
viduals is  manifested ;  but  when  the  moral  sense  is  deficient,  affection 
is  elementary  or  absolutely  wanting,  so  that  kindness  is  either  unappre- 
ciated or  at  once  forgotten. 

There  are  variations  of  the  same  nature  in  love  for  the  family  and  in 
friendship.  Absent  in  the  simplest  idiots,  it  may  be  shown  in  greater 
or  less  degree  in  the  higher  grades.  In  some  it  is  unstable,  changeable, 
and  influenced  much  by  the  selfishness  of  the  individual.  In  others 
again,  there  is  a  perversion  of  family  love,  so  that  they  are  hateful  and 
disagreeable  to  their  parents  or  brethren.  It  is  much  the  same  with 
friendship.  Often  mild  types  of  idiocy  form  in  asylums  friendships  for 
one  another,  though  they  are  too  often  apt  to  be  associations  of  a  sexual 
nature  or  for  the  purpose  of  combining  together  for  mischievous  pur- 
poses. A  true  solidarity  of  interests  or  social  proclivity  is  seldom 
observed.  Maltreatment  of  animals  by  idiots  is  usually  due  to 
ignorance,  but  there  are  moral  imbeciles  who  perpetrate  cruelties  on 
animals  as  well  as  human  beings  from  pure  perversity  and  love  of  in- 
flicting pain.  The  passion  of  love,  when  it  exists,  which  is  extremely 
rare,  is  founded  altogether  upon  a  physiological  basis.  Jealousy  is 
sometimes,  though  infrequently,  observed. 

Pity  is  quite  unknown  in  all  degrees  of  idiocy.  Some  are  amused  or 
curious  and  some  alarmed  at  the  sufferings  of  others. 

Fear  is  a  common  sentiment  in  all  types  of  cases,  more  common  than 
in  normal  persons,  because  of  the  want  of  understanding.  Often  the 
simplest  occurrences  inspire  fear.  On  the  other  hand,  when  much 
excited,  there  are  types  that  exhibit  no  fear  at  all. 

Courage  is  wanting  in  all  classes  of  idiocy.  Anger  is  apt  to  manifest 
itself  in  all  degrees  and  in  every  age.  It  is  apt  to  be  both  causeless 
and  paroxysmal,  and  to  lead  to  the  infliction  of  injuries  upon  the  indi- 
vidual himself,  upon  inanimate  things,  or  upon  persons  in  the  vicinity. 
The  ungovernable  rage  is  usually  increased  by  efforts  to  restrain  the 
patient. 

Acquisitiveness  is   shown  in  imbeciles  and  the  feeble-minded  by    a 

propensity  for  the  collection  of  all  sorts  of  useless  objects  and  trifles, 

much  the  same  as  in  cases  of  chronic  mania.     There  is  often  a  marked 

tendency  to  steal,  sometimes  deliberately,  and  at  other  times  without 

50 


786  MENTAL   DISEASES. 

motive,  merely  to  gratify  the  desire  of  possession.  The  lower  orders 
appropriate  everything  coming  in  their  way,  having  no  regard  for  the 
property  of  others.  Many  can  be  taught  acquisition  as  a  reward  for 
labor,  and,  on  the  other  hand,  there  are  some  who  can  be  made  to  work 
only  through  fear,  having,  as  they  do,  an  innate  antipathy  to  occupation 
of  any  kind. 

With  respect  to  rights  and  duty,  the  perceptions  of  the  idiot  vary  with 
the  degree  of  mental  and  moral  defect.  In  some  even  inferior  idiots 
these  perceptions  may  be  present,  while  with  some  the  rights  of  others 
are  never  respected,  though  to  their  own  they  may  cling  tenaciously, 
and  the  feeling  of  duty  may  never  be  instilled  into  them,  because  of 
more  or  less  moral  perversion. 

Obedience  and  respect  for  authority  vary,  too,  with  the  amount  of  intel- 
ligence and  the  degree  of  moral  impairment.  Quite  simple  idiots  may 
quickly  respond  to  the  word  of  command.  On  the  other  hand,  some  of 
the  most  intelligent  may  perversely  resist  all  attempts  at  discipline. 
Compensation  and  punishment  affect  them  variously.  Reward  in  object- 
ive shape  or  in  the  form  of  praise  is  seldom  appreciated  by  inferior 
grades,  and  often  unduly  by  the  higher.  Punishment,  objective  or  in 
the  form  of  blame,  is  useless  for  the  simpler  degrees  of  idiocy,  where 
acts  are  unintentional,  and  in  some  of  the  more  intelligent  excites  antip- 
athy, an  unreasonable  sense  of  injustice,  and  often  causes  them  to  harbor 
a  vengeful  feeling. 

A  true  religious  sentiment  is  quite  unknown  in  any  form  of  idiocy. 
This  is  true  also  of  the  feeling  of  shame.  The  only  esthetic  sentiment 
found  in  these  defectives  is  the  love  of  music  or  rhythm,  which  is  quite 
general  among  all  classes,  though  not  perhaps  so  noteworthy  as  it  has 
sometimes  been  stated  to  be.  Occasionally  we  meet  with  cases  having 
unusual  musical  aptitude.  It  is  rather  a  rhythmic  noise  which  appeals 
to  most  of  them,  such  as  beating  of  a  drum,  hammering,  the  grinding  of 
an  organ  (even  if  out  of  tune  and  discordant).  They  have  no  sense  of 
beauty,  but  things  bizarre,  grotesque,  glittering,  and  colossal  attract 
their  attention.  Curiosity  and  astonishment  are  aroused  more  readily 
through  the  sense  of  sight  than  that  of  hearing,  and  are  often  more  easily 
roused  in  some  of  the  lower  grades  than  in  the  higher  types  of  idiocy. 

All  classes  evince  a  marked  credulity,  and  often  it  is  difficult  or 
impossible  to  eradicate  an  idea  once  established.  Fairy  stories  are 
especially  pleasing  to  many  of  them,  just  as  they  are  to  children. 

Veracity  is  a  virtue  which  is  uncommon  among  idiots.  Many  imbe- 
ciles are  particularly  apt  to  be  untruthful  and  deceitful  with  regard  to 
their  faults,  doings,  physical  condition,  things  found  in  their  possession, 
and  the  like.  Naturally,  the  simple  idiot,  owing  to  his  feebleness  of 
invention,  if  given  to  lying,  limits  his  untruths  to  the  simplest  matters, 
such  as  denials  of  accusations  brought  against  him,  etc. 

Physiognomy  and  Expression  and  Character. — Idiots  all  show 
deficiency  in  their  general  appearance.  There  is  always  something 
ungracious,  uncouth,  ugly  in  their  figures,  faces,  attitudes,  or  move- 
ments. Very  common  among  them  are  misshapen  or  asymmetrical 
heads,   dwarfishness,   lack    of  proportion    of  the   limbs,  stooping    and 


IDIOCY.  7H7 

slovenly  postures,  deformities  of*  the  hands  or  feet,  and  awkward  and 
wobbling  gait.  The  expression  of  the  face  varies  from  complete  apathy 
and  absence  of  intelligence  to  a  considerable  play  of  features  of  a  Low 
order,  such  as  constant  laughing,  making  faces,  leering,  or  scowling. 
Besides  the  absence  of  those  facial  traits  which  are  made  on  the  face  by 
the  mind,  the  ugliness  is  generally  added  to  by  asymmetry,  dispropori  ion 
or  deformity  of  the  features.  The  eyes  may  be  too  close  together  or 
too  far  apart,  or  deformed  by  disease  of  the  iris,  cornea,  or  lids,  or 
by  squint.  The  nose  deviates  or  is  malformed,  the  ears  are  unshapely 
and  unequal,  the  mouth  half  open,  the  teeth  diseased  and  neglected;  the 
chin  deviated,  prominent,  or  retreating  ;  the  forehead  low  and  bulging  or 
inclined.  Microcephalus,  hydrocephalus,  and  cretinism  give  their  own 
ugly  individuality  too  well  known  to  need  description  here.  Where  a 
head  is  shapely  and  a  face  has  any  vestige  of  pleasing  lines,  it  is  gener- 
ally fair  to  infer  that  the  mental  state  is  due  to  deprivation  of  one  or 
more  senses,  or  to  the  insanity  of  childhood. 

As  to  character,  this,  too,  varies  with  the  amount  of  mental  defect, 
and  is  difficult  to  analyze.  In  profound  idiots  there  are  often  sudden 
accesses  of  excitement  without  apparent  cause.  In  higher  types  the 
basis  of  character  is  inconstancy,  weakness  of  will,  and  blunting  of 
the  sensibilities,  their  humor  depending  largely  upon  their  environment, 
showing  an  appreciation  of  kindness  and  resentment  of  ill-usage. 
Some  are  clever  and  good-natured  and  funny,  often  making  sharp  re- 
marks or  doing  amusing  things,  and  at  one  time  such  cases  were  in 
great  demand  as  court  or  family  fools.  History  shows  there  were  two 
kinds  of  fools  made  use  of  by  royal  and  noble  families — the  true  or 
natural  fools  (idiots  or  imbeciles),  who  were  the  first  to  create  the  pro- 
fession, and  their  crafty  imitators,  the  artificial  fools,  who  made  of  it  a 
profitable  calling. 

I  should  differ  entirely  from  Sollier  in  his  somewhat  extraordinary 
distinction  of  imbeciles  from  idiots.  He  really  selects  one  type  of 
imbecile,  while  we  know  that  there  are  many,  and  erects  this  single 
type  into  a  great  class  which  he  everywhere  distinguishes  in  his  book 
as  the  imbecile.  To  him  the  imbecile  is  egotistical,  boastful,  vicious, 
careless,  dangerous,  a  glutton,  a  vagabond,  a  mischief-maker,  a  sexual 
pervert,  unstable,  lazy,  abusive,  obscene,  forgetful  of  kindness,  venge- 
ful, shameless,  and  altogether  antisocial. 

Language. — The  primitive  physical  basis  of  language  in  the  nor- 
mal human  infant  is  the  auditory  tract  and  the  word-hearing  center. 
It  is  essentially  receptive.  Then  develops  the  word-comprehending 
center.  After  this  the  motor  speech  center  is  developed  and  associated 
with  the  primitive  physical  basis,  thus  establishing  the  emissive  faculty. 
This  rudimentary  linguistic  apparatus  is  variously  defective  in  idiots. 
A  defect  in  the  emissive  power  is  not  so  serious,  as  regards  intelligence, 
as  one  in  the  receptive  ;  for  idiots  of  considerable  intelligence  may  not 
be  able  to  talk  at  all,  while  others  very  inferior  may  speak  with  readi- 
ness. Any  part  of  this  original  physical  basis  of  language  may  be 
affected,  and  the  result  to  the  defective  individual  will  depend  much 
upon  what  function  is  lost.     The  auditory  apparatus  may  be  imperfect. 


788  MENTAL   DISEASES. 

The  word-hearing  center  may  not  act.  The  word-comprehending  cen- 
ter may  be  undeveloped.  In  such  instances  the  intellect  will  suffer 
severely.  Unlike  the  normal  child,  which  comprehends  many  things 
said  to  it  as  early  as  nine  months  of  age,  in  cases  of  this  kind  compre- 
hension will  develop  very  late,  or  perhaps  never ;  yet  occasionally  with 
the  development  of  the  emissive  power  (without  the  word-comprehend- 
ing center)  words  may  be  heard,  learned,  and  repeated,  constituting  an 
echolalia — speech  without  idea.  Supposing  the  emissive  apparatus  alone 
to  suffer,  we  have  hearing  and  comprehension  and  the  development  of 
the  mind,  yet  without  the  power  of  speech. 

Like  an  animal,  the  idiot  may  be  intelligent,  but  speechless.  The 
development  of  language  and  intelligence  is  not  parallel.  Sollier  dis- 
tinguishes two  kinds  of  mutism  in  idiots — a  motor  and  a  sensory  aphasia. 
In  the  first  he  can  not  talk,  though  he  understands ;  in  the  second, 
nothing  which  is  said  is  understood.  Language  is  very  late  in  develop- 
ment in  idiots.  The  crowing  of  the  normal  infant  is  not  often  observed, 
but  meaningless  and  monotonous  cries  take  its  place.  The  laryngeal 
sounds  are  earliest  and  best  enunciated,  the  lingual  and  labial  latest  and 
least  distinctly.  Wildermuth  classifies  the  dysarthrias  and  lalopathies 
of  idiots  into  two  groups  : 

1.  Where  the  disturbance  of  speech  is  the  direct  expression  of  the 
intellectual  density.  They  lack  ideas,  and  consequently  have  not  the 
words  for  the  expression  of  them.  In  the  lowest  degree,  the  idiot  is  a 
vegetative  automaton ;  in  a  less  profound  degree,  he  is  like  a  child  of 
two  or  three  years,  with  imperfections  of  grammar  and  syntax. 

2.  When  the  disturbance  of  speech  is  a  complication  of  idiocy,  and 
is  mechanical  rather  than  intellectual,  Wildermuth  has  rarely  found 
stumbling  speech  in  the  idiot,  and  never  stammering.  These  defects 
are  sometimes  found  in  imbeciles,  who,  moreover,  talk  a  great  deal  and 
without  definite  object ;  who  have  onomatomania,  and  who  are  subject 
to  transitory  attacks  of  excessive  and  maniacal  loquacity. 

Considerable  loquacity  is  occasionally  observed  in  cases  of  acquired 
idiocy. 

Next  to  hearing,  the  visual  tract  and  the  word-seeing  and  compre- 
hending centers  form  a  great  receptive  avenue  for  language  and  ideas. 
Reading  will  be  impossible  to  such  idiots  as  have  defect  of  the  visual 
apparatus  or  these  centers,  and  the  degree  of  acquisition  of  this  power 
will  depend  upon  the  degree  of  defect.  There  are  idiots  who  learn 
merely  the  letters,  others  who  acquire  monosyllables,  and  still  others 
who  can  be  taught  to  read  laboriously.  Sometimes  such  reading  is 
purely  automatic,  without  actual  comprehension.  The  higher  the  grade 
of  idiocy,  imbecility,  or  feeble-mi ndedness,  the  greater  the  develop- 
ment of  this  faculty,  though  few  of  either  class  ever  attain  to  perfectly 
correct  reading. 

The  writing  center  and  its  association  tracts  are  the  latest  portions  of 
the  linguistic  cerebral  basis  to  be  established  in  normal  cases,  and  in 
the  idiot  are  apt  to  be  the  least  well-constituted.  In  addition  to  its  in- 
tellectual side,  there  is  a  complicated  muscular  coordination  required  in 
writing:  which  also  renders  it  more  difficult  for  defectives  of  this  kind. 


IDIOCY.  789 

They  may  be  taught  to  reproduce  letters,  but  the  characters  are  mean- 
ingless to  them.  A  few  write  quite  legibly,  though  seldom  or  never 
well.  As  Sollier  says,  their  writing  is  in  reality  drawing,  and  they 
like  to  copy  printed  letters,  curved  lines,  and  so  on.  There  is  a  certain 
tendency  to  write  with  the  left  hand  and  to  write  from  right  to  left. 

In  drawing,  such  as  learn  at  all  copy  slowly  and  uncertainly,  with- 
out perspective,  and  never  draw  without  a  copy  or  model  ;  or  they  do 
the  work  impatiently,  and,  if  given  free  rein,  indulge  in  curious  and 
fantastic  scrawls,  such  as  are  figured  in  the  works  of  Sollier,  Bourne- 
ville,  and  others. 

Intelligence. — Since  intelligence  depends  upon  the  acquisition,  con- 
servation, association,  and  production  of  ideas,  and  these  upon  the  con- 
dition of  the  sensory  organs  and  centers  and  language  centers,  it  is 
mainly  in  intelligence  that  the  idiot  deviates  from  normal  man.  The 
deviation  varies  much  in  degree,  from  almost  total  absence  to  a  condi- 
tion nearly  approaching  the  normal.  The  idiot  has  fewer  ideas  than 
the  imbecile,  and  the  imbecile  fewer  than  the  feeble-minded.  All 
classes  acquire  ideas  primarily  in  the  same  way  as  the  normal  infant — 
through  the  senses  ;  but  while  the  normal  child  later  on  acquires  ideas 
chiefly  by  means  of  language  and  imitation,  the  defective  continues  to 
make  use  mainly  of  the  senses  for  this  purpose,  owing  to  the  faulty 
development  of  the  language  centers.  Preyer  shows  that  questions 
and  names  are  understood  before  the  normal  child  can  speak  (nine 
months),  while  idiots,  many  years  of  age,  may  have  an  intelligent  idea 
of  the  use  of  things,  yet  not  know  their  names  when  heard,  and  be 
unable  to  speak  them. 

As  regards  concrete  ideas,  such  as  the  different  qualities  of  matter, 
it  is  noticeable  that  the  idiot  appreciates  colors  (particularly  red),  rec- 
ognizes surfaces,  avoids  obstacles,  and  notices  the  difference  between 
round  and  square,  while  distances  and  space  are  not  comprehended.  As 
Sollier  correctly  says,  imitation,  which  is  a  source  of  ideas  for  infants, 
does  not  develop  the  intelligence  of  the  idiot ;  for  to  him  it  does  not 
furnish  an  idea,  but  creates  a  mechanism.  In  the  superior  grades  of 
idiocy  imitation  creates  an  idea  which  is  assimilated  by  the  intelligence  ; 
but  as  the  intelligence  can  not  retain  it,  the  result  is  the  same  as  though 
it  had  not  been  assimilated.  Still,  it  is  not  just  to  infer,  from  lack  of 
intellectual  expression,  that  there  is  complete  intellectual  inactivity. 
That  ideas  may  exist  in  a  brain  apparently  inactive  is  shown  by  the 
phenomenon  of  intellectual  manifestation  induced  in  idiots  by  severe 
pain,  disease,  etc.  In  other  words,  the  intellectual  receptivity  of  idiots 
may  be  greater  than  supposed,  until  some  irritation  occurs  strong 
enough  to  show  that  the  preceding  stimuli  have  left  their  effects  on  the 
brain  centers.  Thus,  Griesinger  reports  the  case  of  an  idiot  who  could 
only  speak  a  few  words  until  he  contracted  hydrophobia,  when  he  began 
to  talk  of  events  which  had  taken  place  several  years  before. 

As  regards  the  conservation  of  ideas,  we  must  remember,  says  Sollier, 
that  memory  is  hereditary,  organic,  or  acquired.  Hereditary  memory 
is  extremely  complex  and  difficult  of  explanation,  but  it  apparently 
occurs  in  idiots.     Organic  memory,  or  unconscious  memory, — viz.,  of 


790  MENTAL   DISEASES. 

associated  movements,  such  as  walking, — although  sometimes  completely- 
absent  in  idiots,  owing  to  defective  nerve  centers  and  lack  of  attention, 
is,  nevertheless,  better  developed  than  either  of  the  two  other  varieties. 
For  acquired  memory,  attention  is  still  more  a  sine  qua  non,  and  conse- 
quently this  is  the  least  developed  form  of  memory  in  idiots.  Memory 
in  an  idiot  develops  slowly ;  at  first  its  existence  is  shown  only  by  the 
stimulus  of  some  violent  excitement.  This  indicates  that  memory  exists 
in  so  far  as  the  conservation  of  the  image  is  concerned,  but  not  enough  for 
its  reproduction  under  ordinary  circumstances.  In  a  higher  degree  of 
the  development  of  memory,  the  idiot  can  recall  the  memory  picture  by 
seeing  again  the  original  object  (memory  for  food,  memory  for  places). 
Local  memory,  which  does  not  act  by  satisfaction  of  a  natural  need,  is 
only  found  in  educable  idiots  (remembers  his  own  bed,  etc.).  This 
memory  is  fixed  by  repetition  of  the  sensation,  and  has  not  an  emotional 
basis.  These  varieties  of  memory  are  simple,  and  do  not  necessitate 
language.  As  soon  as  language  exists,  a  much  wider  field  opens  for  the 
memory. 

In  simple  idiots  there  is  no  association  of  ideas.  The  primitive 
forms  of  association,  such  as  fear  and  the  hope  of  reward,  awaken  no 
associated  ideas  in  them,  and  even  in  the  superior  types  of  idiocy  there 
is  no  great  development  of  this  form  of  memory. 

It  is  a  curious  and  inexplicable  phenomenon  that  in  certain  cases  of 
idiocy  there  may  exist  particular,  specialized  memories,  such  as  for 
musical  airs,  dates,  and  numbers,  although  memory,  in  its  usual  and 
general  sense,  may  be  deficient.  Indeed,  as  a  rule,  the  memory  is  feeble 
in  all  classes  of  idiocy,  and  even  in  cases  where  the  memory  is  fairly- 
well  constituted  it  is  ordinarily  mechanical,  useless  to  the  possessor, 
automatic. 

Naturally,  as  abstract  ideas  result  from  reason,  comparison,  and 
judgment,  such  ideas  are  absent  in  the  lowest  order  of  idiocy.  Pro- 
found idiots  have  no  idea  of  differences  of  persons  or  things.  Higher 
idiots  may  be  able  to  appreciate  superficial  resemblances  and  differences, 
especially  of  color  and  form,  but  the  discernment  is  so  faulty  that 
incorrect  inferences  frequently  result. 

Superior  idiots  appreciate  resemblances  more  readily  than  differences. 
Simple  generalizations  may  be  possible,  however,  to  all  classes.  In  the 
lower  types  such  generalizations  occur  only  after  long  instruction,  and, 
once  this  power  is  acquired,  they  may  be  fairly  correct,  but  in  many  of 
the  higher  they  are  hasty  and  often  faulty.  In  educable  idiots,  even 
those  who  can  not  talk,  there  is  an  appreciation  of  number,  and  they 
may  be  taught  to  count.  Addition  is  more  easily  learned  than  subtrac- 
tion, and  multiplication  can  only  be  learned  by  those  with  fairly 
developed  memories.  Division  can  rarely  be  taught  them,  and  neither 
idiots  nor  imbeciles  can  understand  problems.  The  superior  orders  of 
idiocy  can  count  automatically,  but  rarely  are  able  to  do  so  with  proper 
understanding.  They  can  say  two  and  two  make  four,  four  and  four 
make  eight ;  but  ask  them  how  many  are  four  and  three  and  they  are 
at  sea.  To  count  beyond  ten,  the  number  of  the  fingers,  is  rarely 
learned.     But  there  are  phenomenal  instances  where  the  mathematical 


IDIOCY.  79  J 

faculty  is  remarkably  (level* >ped,  as  in  the  eases  of  the  so-called 
"calculating'  boys,"  some  of  whom,  it  is  true,  are  normal  in  other 
respects,  but  many  of  whom  are  mentally  defective,  belonging  to  tin- 
category  of  idiots  or  imbeciles. 

The  idea  of  time,  past  and  future,  has  seldom  a  place  in  the  brain 
of  the  idiot. 

Ideas  in  the  idiot  are  too  feeble  to  be  fixed  ideas,  and  while  tin- 
higher  types  are  sometimes  subject  to  morbid  impulses,  there  is  not  a 
true  fixed  idea,  with  consciousness  and  pain.  With  them  such  ideas 
should  rather  be  called  tenacious  ideas. 

The  association  of  ideas  occurs  by  resemblance,  contrast,  and  con- 
tiguity. In  the  profound  idiots,  with  few  ideas,  there  may  be  an  asso- 
ciation of  them  in  a  very  simple  way — viz.,  the  sight  of  food  is  asso- 
ciated with  the  sensation  of  satisfied  hunger,  and  so  awakens  the  idea 
of  eating.  It  is  an  association  of  sensations  rather  than  of  ideas.  The 
association  of  ideas  should  arouse  the  critical  faculty.  The  judgment 
and  reason  in  idiots  are  very  faulty.  They  are  founded  on  an  associa- 
tion of  few  ideas,  lack  precision  and  firmness,  and  find  their  expressions 
in  ambiguous  language.  A  judgment  is  not  always  the  result  of  reason- 
ing. For  reasoning,  there  must  be  some  obstacle  to  an  immediate  con- 
clusion. Justice,  promptitude,  and  firmness,  which  are  qualities  of 
judgment  depending  on  the  attention,  are  lacking  in  the  judgments  of 
idiots.  The  idiots  judge  very  falsely  on  account  of  lack  of  attention 
and  of  an  association  of  the  simplest  ideas.  All  their  sense  illusions 
give  rise  to  false  judgments.  Firmness  is  lacking  in  their  judgments, 
as  they  have  so  little  interest  in  what  they  decide  upon. 

Many  imbeciles  and  feeble-minded,  however,  maintain  their  judg- 
ments with  tenacity.  They  often  have  a  very  high  opinion  of  their 
own  intellectual  faculties.  '  This  presumption  leads  them  often  to  ex- 
treme blunders.  If  one  of  their  judgments  is  admitted  to  be  just,  they 
become  very  proud  of  it,  and  immediately  set  to  work  to  form  others, 
which  are  generally  absurd.  Doubt  which  suspends  action  is  rarely 
seen  in  any  form  of  idiocy.  The  first  impression  capable  of  forming 
for  them  a  judgment  is  followed  immediately  by  the  act,  like  a  true 
reflex.  Syllogistic  reasoning  does  not  occur  either  in  idiots  or  imbe- 
ciles. Errors  of  the  senses  proceed  from  the  perceptive  apparatus 
rather  than  from  the  sensory  apparatus.  Since  in  idiots  and  imbeciles 
sense  perceptions  are  retained  in  brain  centers  either  undeveloped  or 
diseased,  and  the  memory  pictures  are  consequently  either  confused  or 
false,  the  association  of  these  pictures  is  consequently  faulty.  In 
idiots,  as  the  images  are  weak,  the  perceptive  reasoning  is  also  weak  or 
wanting.  In  the  imbecile,  where  the  images  are  more  numerous,  the 
association  may  be  falsified  by  a  badly  acting  perceptive  center.  In 
him  the  association  occurs  so  often  by  contiguity,  and  consequently  the 
deduction  is  very  liable  to  be  erroneous,  as  contiguous  ideas  are  not 
necessarily  related  ;  hence,  incongruous  observations  and  unexpected 
actions.  . 

Sollier  emphasizes  the  difference  between  idiots  and  imbeciles,  which 
may    be  seen   in   the  delirium    sometimes    occurring   in    these   cases. 


792  MENTAL   DISEASES. 

Exceptional  in  the  idiot,  when  it  occurs  it  is  always  in  the  impulsive 
form,  unprovoked  and  without  motive.  It  is  a  delirium  of  acts.  In 
imbeciles  there  are  attacks  of  maniacal  excitement,  with  impulsion  to 
kill,  to  set  on  fire,  or  to  break. 

With  respect  to  the  production  of  ideas,  there  is  little  or  none  in  the 
inferior  types  of  idiocy,  and  in  the  higher  grades  the  imagination  is 
inchoate,  of  no  utility,  and  often  directed  to  things  that  are  evil. 

"Will,  Personality,  and  Responsibility. — The  elder  Seguin  looked 
upon  defect  of  will  as  the  basis  of  idiocy,  but  the  will  is  rather  a  diffuse 
than  a  local  function  of  the  brain.  It  has  no  definite  seat  in  the 
encephalon,  lesion  of  which  would  impair  or  destroy  it.  As  Sollier 
says,  will  in  its  simplest  form  is  manifested  by  actions  accomplished  for 
the  satisfaction  of  natural  needs,  appetites,  and  desires.  Accordingly, 
the  individual  must  have  a  consciousness  of  those  needs.  Such  a  con- 
sciousness may  be  very  much  blunted  in  profound  idiots,  and  conse- 
quently the  will  will  be  almost  entirely  lacking.  Such  an  idiot  is  a 
spinal  being,  and  his  movements  may  be  compared  to  the  reflex  phe- 
nomena seen  in  decapitated  frogs.  In  higher  idiots,  the  will  is  mani- 
fested by  more  complex  movements,  which  are,  however,  capable  of 
becoming  secondarily  automatic.  Voluntary  control  of  the  sphincters 
occurs  only  in  idiots  who  learn  to  walk,  and  not  until  they  have  learned. 
Volitions  do  not  exist  in  the  lowest  order  of  idiots.  The  most  natural 
desires  and  the  most  primitive  instincts  are  absent.  The  first  to  appear 
is  desire  for  food,  but  it  may  manifest  itself  simply  by  a  stretching 
out  of  the  hand  or  a  cry.  In  idiots  in  whom  the  will  is  more  developed, 
and  also  in  imbeciles,  it  finds  its  expression  more  easily  in  actions  than 
in  inhibitions. 

Self-respect,  very  little  developed  in  the  idiot,  plays  a  very  important 
role  in  the  psychology  of  the  imbecile,  and  by  catering  to  it  he  can 
often  be  made  to  do  things  which  would  otherwise  be  impossible  to 
obtain. 

Intellectual  movements,  or  acts  accomplished  under  the  influence  of 
judgment  or  reason,  are  infrequent  in  the  idiot,  and  not  common  in  the 
higher  grades.  Many  idiots  are  incapable  of  choice.  When  the  power 
of  choice  is  present,  it  is  often  exercised  with  difficulty.  He  does  not 
quickly  understand  that  of  two  things  he  must  take  one  and  leave 
the  other — he  wants  to  take  them  both.  It  is  the  same  with  ideas. 
Between  two  desirable  objects,  the  superior  type  does  not  hesitate,  but 
takes  without  reflection  the  one  he  sees  first,  which  he  may  wish  to 
exchange  when  he  sees  the  second. 

In  idiots,  whose  will  and  motor  volitions  are  so  feeble,  suggestion 
produces  little  or  no  results.  It  is  the  contrary  in  many  imbeciles, 
except  in  those  whose  voluntary  impulsiveness  is  too  great.  Ordinarily 
the  higher  grades  are  very  susceptible  to  suggestion,  as  is  seen  by  the 
facility  with  which  mischief  is  done  by  a  band  of  imbeciles  which  has 
been  led  on  by  one  of  their  number.  If  suggestion  is  possible  in 
imbeciles,  it  shows  that  the  ideas  which  they  already  possess  are  very 
unstable,  and  are  easily  replaced  by  new  ones.  It  has  a  great  analogy 
with  the  suggestibility  of  the  hysterical. 


IDIOCY.  793 

Consciousness  and  Personality. — As  consciousness  is  but  a  phe- 
nomenon added  to  psychic  processes,  and  not  producing  them,  and  as 
the  personality  is  the  coordination  of  psychic  acts,  it  is  necessary  to 
form  by  deduction  our  conclusions  as  to  these  two  attributes  in  the 
•class  of  people  we  are  studying.  In  absolute  idiots  it  is  not  probable 
that  any  act  is  accompanied  by  consciousness.  In  higher  idiots,  in 
whom  life  is  but  little  more  than  a  succession  of  disconnected  moments, 
it  is  not  possible  to  say  whether  they  have  consciousness  or  not ;  but  the 
personality,  if  present,  must  be  very  rudimentary,  since  an  essential 
of  its  existence  is  a  proper  appreciation  of  the  continuity  of  events. 

For  an  individual  to  have  consciousness  of  a  psychic  act,  it  is 
necessary  that  the  exciting  stimulus  have  a  certain  duration  and  inten- 
sity. Such  factors  in  the  stimuli  are  generally  wanting  in  idiots  ;  and 
so  it  is  probable  that  most  of  their  psychic  phenomena  occur  without 
consciousness  ;  and  if  there  is  consciousness,  it  must  be  very  feeble. 
The  distinction  between  the  ego  and  the  non-ego  is  not  made  by  abso- 
lute idiots,  and  is  but  feebly  present  in  the  higher  idiots. 

In  many  imbeciles  consciousness  may  be  wanting  or  feeble,  but  in 
some  it  is  clearly  present,  together  with  a  perfect  idea  of  their  per- 
sonality. Further,  sometimes  in  delirium  they  have  ideas  of  grandeur, 
showing  an  exaggerated  conception  of  personality. 

Responsibility. — All  lower  types  of  idiots  are  unable  to  manage 
their  own  affairs  or  to  enjoy  their  civil  or  political  rights,  but  those  of  a 
higher  degree,  who  are  at  liberty,  may  have  these  rights. 

Psychological  Evolution. — In  every  degree  of  idiocy  there  comes 
a  time,  as  Sollier  well  says,  when  the  education  stops  and  further  mental 
progress  ceases,  and  when  the  only  hope  is  to  retain  the  results  which 
have  been  gained.  This  acme  of  development  varies  for  the  different 
psychic  functions,  so  that  one  faculty  may  still  improve,  while  another 
has  already  reached  its  cessation  point.  The  senses  continue  to  develop 
for  the  longest  time,  then  the  sentiments,  and  the  intelligence  the 
shortest.  This  is  true  of  all  classes,  though  the  periods  are  longer  in 
the  higher  grades,  where  all  of  the  faculties  are  more  equally  and  pro- 
portionally developed.  Thus,  in  inferior  types  intellectual  progress 
may  cease  at  the  age  of  six  or  seven,  and  the  sentiments  and  senses  con- 
tinue their  development  to  eighteen  or  twenty,  while  in  superior  grades 
the  improvement  of  senses,  sentiments,  and  intellect  may  cease  about 
the  same  time — viz.,  at  puberty. 

Sometimes  the  faculties  remain  stationary,  at  others  they  retrograde 
when  the  limit  of  development  is  reached.  Retrogression  follows  the 
same  law  as  dementia — namely,  progressive  enfeeblement  of  will,  intel- 
ligence, sentiments,  and  sensations,  in  the  order  named.  When  retro- 
gression begins  in  the  simpler  forms  it  is  very  rapid,  but  in  the  higher 
types  goes  more  slowly  and  more  irregularly.  Purely  intellectual  gifts 
which  they  have  acquired  (reading  and  writing)  disappear  very  rapidly. 
In  the  intellectual  downfall  of  the  superior  types  one  sees  from  time  to 
time  flashes  of  intelligence,  like  reflections  from  their  weakening  minds, 
but  such  are  not  observed  in  the  lower  forms. 

General  Pathological  Anatomy. — There  has  been  accumulated  in 


794  MENTAL   DISEASES. 

literature  of  late  years  a  great  deal  of  valuable  matter  relating  to  the 
pathology  and  morbid  anatomy  of  idiocy,  so  that  much  new  light  has- 
been  shed  upon  a  somewhat  obscure  subject.  The  investigations  of 
Sachs  and  myself 1  into  the  causation  of  the  cerebral  paralyses  of  chil- 
dren, which  are  so  frequently  associated  with  the  various  degrees  of 
mental  impairment,  from  feeble-mindedness  to  profound  idiocy,  and  in 
which  we  found  meningeal  hemorrhage  to  be  so  commonly  the  primary 
lesion,  might  well  give  rise  to  the  belief  that  in  a  majority  of  cases  of 
idiocy  without  paralysis  and  in  idiocy  associated  with  epilepsy  we  are 
confronted  with  the  same  initial  lesion.  The  site  of  the  meningeal 
hemorrhage  is  the  determining  factor  in  the  establishment  of  the  symp- 
toms. If  the  Rolandic  area  be  mainly  implicated,  either  on  one  or  on 
both  sides,  we  have  a  hemiplegia  or  diplegia  as  the  result,  and  these 
paralyses  may  be  severe  or  light  according  to  extent  of  the  hemorrhage, 
and  may  be  associated  with  idiocy  or  epilepsy,  depending  also  upon  the 
extent  of  the  lesion  and  upon  the  amount  of  irritation.  Again,  I  have 
seen  a  case  in  which  there  was  left  hemianopia,  epilepsy,  and  very  slight 
mental  impairment,  pointing  to  a  meningeal  hemorrhage  over  the  right 
occipital  lobe.  Probably,  too,  some  of  the  cases  of  arrested  devel- 
opment of  the  speech,  with  or  without  enfeebled  mind,  are  due  to 
the  same  cause.  It  may  be  assumed  also  that  meningeal  hemorrhage 
often  occurs  as  the  initial  lesion  in  what  appears  to  be  idiopathic  epi- 
lepsy. The  symptom  or  syndrome  produced  then  will  depend  upon 
the  location  and  extent  of  the  initial  lesion.  Asphyxia  at  birth  and 
convulsions  shortly  after  birth  are  in  themselves  significant  of  menin- 
geal hemorrhage,  and  in  our  study  of  etiology  we  observe  the  great 
frequency  of  these  symptoms  in  the  history  of  idiocy.  At  our  autop- 
sies, which  are  nearly  always  made  years  after  the  initial  lesion,  we 
find  only  terminal  pathological  states,  such  as  atrophy,  general  sclerosis,, 
and  cysts,  and,  unfortunately,  these  conditions  are  not  pathognomonic  of 
antecedent  hemorrhage,  for  they  also  are  the  terminal  states  for  em- 
bolism, thrombosis,  cerebral  hemorrhage,  meningitis,  and  meningo- 
encephalitis. What  other  evidence  have  we  that  proves  the  enormous 
preponderance  of  meningeal  hemorrhage  in  the  etiology  of  the  terminal 
pathological  conditions  ?  It  is  in  the  testimony  of  the  investigators  of 
the  causes  of  still-birth.  For  instance,  Litzmann2  examined  161  still- 
born children,  finding  in  them  35  cases  of  meningeal  hemorrhage.  Par- 
rot,3 in  34  autopsies  on  the  new-born,  found  5  with  blood  in  the  arach- 
noid cavity  and  26  with  hemorrhage  into  the  subarachnoid  space. 

The  study  of  Sarah  J.  McNutt,4  of  New  York,  in  1885,  of  10 
similar  cases  added  valuable  testimony  to  that  already  given,  and 
showed  the  relation  between  meningeal  hemorrhage  and  asphyxia  and 
convulsions  in  the  new-born  in  a  manner  not  to  be  gainsaid. 

111  The  Cerebral  Palsies  of  Early  Life,  Based  on  a  Study  of  One  Hundred  and 
Forty  Cases,"  "Jour.  Nerv.  and  Ment.  Dis.,"  May,  1890.  See  also  paper  on  same 
subject  by  author,  Louis  Starr's  ' '  Text-book  of  Diseases  of  Children, "  Phila. ,  1894,  and 
Sachs'  "  Nervous  Diseases  of  Children,"  New  York,  1895. 

2  "  Archiv  fur  Gyn.,"  Bd.  xvi,  1880. 

3  "  Clinique  des  Nouveau-nes, "  Paris.  1877.  4  "  Amer.  Jour,  of  Obstetrics." 


idiocy.  795 

Allusion  is  elsewhere  made  to  Herbert  It.  Spencer's  L30  autopsies 
in  still-born  children,  in  which  there  were  53  instances  of  hemorrhage 
from  the  pia  and  arachnoid. 

Thus,  the  evidence  before  us  in  favor  of  meningeal  hemorrhage  ae 
the  initial  lesion  in  a  large  proportion  of  cases  of  idiocy  is  mosl  con- 
vincing. Some  idea  of  the  character  of  the  terminal  states  found  in 
idiocy  may  be  derived  from  the  studies  of  Wilmarth1  and  Bourneville.2 
The  former  communicates  the  results  of  100  autopsies,  which  he  sum- 
marizes as  follows  : 

Sclerosis  with  atrophy,  12  ;  sclerose  tubercuse,  6  ;  diffuse  sclerotic 
change,  7  ;  degenerative  changes  in  vessels,  ganglionic  cells,  or  medul- 
lary substance,  not  constituting  true  sclerosis,  1 5  ;  hydrocephalic,  5  ; 
general  cerebral  atrophy,  2;  non-development  in  various  forms,  16; 
infantile  hemorrhage,  1  ;    extensive  adhesion  of  membranes   from  old 


Fig.  303. — Brain  of  a  diplegic  idiot,  showing  atrophy  of  the  convolutions  over  large  symmetrical  areas 
— not  a  true  parencephalia.     (See  history  of  case,  "  Proc.  N.  Y.  Path.  Soc,"  1894,  p.  94.) 

meningitis,  3  ;  angiomatous  condition  of  cerebral  vessels  (with  degener- 
ative changes),  1  ;  glioma  (with  sclerosis),  1  ;  porencephalia  (with 
non-development),  1  ;  of  31  cases  where  actual  disease  or  imperfect 
development  of  the  brain  proper  was  not  demonstrated,  there  was 
hypertrophy  of  the  skull,  6  ;  acute  softening  (recent),  2  ;  demimicro- 
cephalic,  2  ;  when  the  brain  was  above  usual  weight,  but  the  convolu- 
tions large  and  very  simple  in  their  arrangement,  2. 

Our  examination  of  this  summary  discloses  the  fact  that  atrophies 
and  diffuse  sclerosis  were  demonstrated  in  21  of  the  cases  and  tuberous 
sclerosis  in  6.  It  is  probable  that  the  tuberous  form  of  sclerosis  has  a 
pathology  different  from  that  of  the  diffuse  form  and  more  resembling 
the  disseminated  sclerosis  of  neuropathologists.  Fifteen  of  Wilmarth' s 
cases  are  recorded  as  presenting  degenerative  changes  in  vessels,  gan- 

1  "Proceedings  Ass'n  Amer.  Inst.  Idiots  and  Feeble-minded,"  1891. 

2  "Recherches  sur  l'epilepsie,  l'idiotie,"  etc.,  Paris,  1880-1897. 


796  MENTAL  DISEASES. 

glionic  cells,  or  medullary  substance,  "  not  constituting  true  sclerosis." 
There  was  evidently  some  resemblance  to  sclerosis,  or  this  author  would 
not  have  qualified  his  description  thus ;  and  it  is  more  than  probable 
that  the  condition  would  have  been  pronounced  one  of  genuine  diffuse 
sclerosis  by  experts  at  the  present  day.  Wilmarth  notes  16  cases  of 
non-development  in  various  forms.     He  writes,  in  this  connection  : 

"  Non-development  is  found  in  several  forms.  A  portion  of  the 
cortical  substance  may  be  thin,  and,  instead  of  following  the  typical 
arrangement  of  the  fully  developed  brain,  form  a  number  of  irregular 
folds,  which  may  be  so  small  and  numerous  as  to  resemble  a  mass  of 
angle-worms." 

This  is  evidently  the  condition  which  we  know  as  microgyria,  a  true 
pathological  process  probably  due  to  a  vascular  lesion  (thrombosis  or 
embolism),  and  not,  therefore,  a  fault  of  development.  Wilmarth's  ob- 
servations were  made,  many  of  them,  years  ago,  before  neuropathology 
had  attained  its  present  precision,  and  hence  have  not  the  value  of  later 
researches,  such  as  those  undertaken  at  Bicetre  and  Upsala. 

Hammarberg  1  has  made  one  of  the  most  valuable  contributions  to 
the  study  of  the  pathology  of  idiocy  in  literature.  His  study  enters 
into  the  details  of  the  examination  of  the  brains  of  nine  cases  of  idiocy, 
imbecility,  and  feeble-mindedness.  Several  of  these  were  epileptic  and 
paralytic  idiots.  His  pathological  investigations  were  controlled  by  the 
microscopic  examination  of  twelve  normal  brains.  The  results  were 
briefly  as  follows  :  In  all  of  the  cases  of  idiocy  a  more  or  less  large 
part  of  the  cortex  showed  arrest  of  development  at  a  stage  correspond- 
ing to  either  an  embryonal  period  or  the  period  of  early  infancy.  Only 
a  small  number  of  cells  reached  their  higher  development  or  were  de- 
stroyed during  the  growth  of  the  cortex.  The  mental  defects  were  in 
direct  proportion  to  the  defects  of  the  development  of  the  cells,  and 
were  greater  the  earlier  the  period  of  arrest  of  development. 

As  regards  hydrocephalic  idiocy,  the  true  pathogeny  of  hydroceph- 
alus is  unknown.  It  is  generally  explained  as  being  due  to  a  chronic 
intraventricular  meningitis,  a  congestion  of  the  ependyma.  But  in 
many  of  these  cases  nothing  abnormal  is  observed  about  the  ependyma 
save  thickening.  It  is  possible  that  a  careful  study  of  the  manner  of 
secretion  of  the  cerebrospinal  fluid  and  of  the  relations  existing  between 
the  ependyma  and  the  external  serous  membrane  of  the  brain  may 
help  to  elucidate  the  origin  of  the  disorder  ;  for  there  is  some  reason  for 
believing  that  a  sort  of  current  of  fluid  flows  from  the  ventricles  into 
the  exterior  serous  cavity  through  the  foramen  of  Magendie,  the 
foramina  of  Mierzejewsky,  and  two  other  foramina  which  have  been 
described,  but  are  of  uncertain  existence.  The  ventricular  walls  secrete 
the  cerebrospinal  fluid  and  the  exterior  serous  cavity  absorbs  it,  accord- 
ing to  this  theory.  Thus,  then,  there  may  be  three  processes  by  which 
primary  hydrocephalus  may  be  induced  :  hypersecretion  in  the  ventric- 
ular spaces,  occlusion  of  the  foramina  mentioned,  and  disorder  of  the 
absorbent  apparatus.  An  interesting  study  of  the  subject  along  this 
line  might  be  made. 

1  ' '  Studien  liber  Klinik  und  Pathologie  der  Idiotie, "  by  C,  Hammarberg,  Upsala, 
1895. 


IDIOCY. 


797 


When  the  fluid  begins  to  increase  in  the  ventricles,  these  become 
dilated,  as  a  rule  equally,  occasionally  unequally,  from  obliteration  of  tlie 
foramen  of  Monro.  The  dilatation  may  be  restricted  to  the  lateral  ven- 
tricles, or  may  include  the  third  and  fourth  also.  With  the  distention 
of  the  ventricles  compression  of  the  brain-substance  take-  place,  giving 
rise  to  functional  impairment  of  various  kinds  and  degrees.  With 
increase  of  pressure,  atrophy  of  the  compressed  parts  occurs.  The 
septum  between  the  ventricles  may  disappear  and  the  brain-envelope 
become  thin   as  paper,  so  that  the  hydrocephalus  is  like  one  enormous 


Fie   304  —Brain  of  a  blind  hemiplegic  idiot.    Atrophy  and  microgyria  in  both  occipital  lobes.     (See 
history  of  case,  "  Proc.  N.  Y.  Path.  Soc,"  1894,  p.  98.) 


cyst  filling  the  cranial  cavity.  The  basal  ganglia  and  brain-stem 
become  flattened.  Examination  of  the  cerebral  envelope  shows  atrophy 
and  degeneration  of  cells  and  fibers.  The  distention  may  go  on  until 
the  cerebral  tissues  and  the  membranes  vanish  almost  entirely.  The 
amount  of  fluid  has  been  known  to  reach  six,  eight,  ten,  twenty,  and 
even  twenty-seven  pints.  The  following  is  an  instance  in  point  (a  case 
from  the  Randall's  Island  Hospital  for  Idiots,  the  autopsy  of  which  I 
reported  at  the  New  York  Pathological  Society.  See  "  Proceedings," 
1894,  p.  94) : 

A  female    child,    aged    eighteen    months ;    hydrocephalus,   whether 


798 


MENTAL  DISEASES. 


congenital  or  acquired  unascertained.  Circumference  of  head,  51.5  cm.  ; 
anteroposterior  diameter,  18  cm.  ;  greatest  transverse  diameter,  15  cm. ; 
naso-occipital  arc,  32  cm. ;  binauricular  arc,  34  cm. 

Blindness  and  nystagmus ;  widely  gaping  fontanels ;  spastic  di- 
plegia ;  occasional  convulsions,  and  just  before  death  opisthotonos. 
At  the  autopsy  sixty-four  ounces  of  reddish  serum  were  first  removed 
by  tapping  the  anterior  fontanel.  The  skull  and  dura  were  exceed- 
ingly thin.  The  falx  cerebri  had  disappeared.  Cutting  through  the 
thin  dura,  nothing  was  to  be  seen  of  any  brain  proper  in  the  great  cavity 
of  the  head.  The  membranes  usually  covering  the  cerebrum  had  dis- 
appeared with  that  organ.  At  the  base  of  the  skull  the  floors  of  the 
ventricles  and  basal  ganglia  stood  out  prominently,  and  back  of  these 
parts,  lying  on  the  tentorium,  were  the  only  vestiges  of  a  cerebrum — 


Fig.  305. — Brain  and  skull  in  a  case  of  hydrocephalus. 


parts  of  the  two  occipital  lobes.  On  removing  the  tentorium,  the  cere- 
bellum was  found  to  be  of  about  normal  size.  Microscopical  exami- 
nation showed  degeneration  and  atrophy  of  the  lateral  columns  of  the 
cord  (Fig.  305). 

In  this  case,  then,  we  have  to  do  with  distention  and  atrophy  of  the 
encephalon  pushed  to  its  greatest  extreme. 

Case  IV,  in  a  series  of  autopsies  by  Bourneville,  is  a  good  illustra- 
tion of  the  nature  of  the  process  of  compression  and  atrophy.  A  girl, 
a  complete  idiot,  died  at  the  age  of  about  two  years.  Five  hundred 
grams  of  fluid  were  found  in  the  brain-cavity,  the  brain-envelope 
having  become  merely  a  sac  of  varying  thickness.  For  instance,  in 
the  right  hemisphere,  over  the  whole  of  the  temporo-occipital  region, 
the  wall  of  cerebral  substance  was  but  a  millimeter  in  thickness,  and 
at  one  place  here,  near  the  fissure  of  Sylvius,  the  brain-substance  was 


idiocy.  799 

absent  altogether  at  a  space  of  four  centimeters  in  diameter,  closed 
merely  by  a  fine  meningeal  veil.  In  this  case,  then,  the  process  of 
complete   atrophy  of  the  brain  was  arrested  by  death. 

As  the  ventricular  cavities  dilate,  pushing  the  brain-envelope  with 
them,  the  skull-cavity  is  distended  and  the  cranial  bones  are  separated, 
made  thinner,  and'  expanded  in  area.  The  enlargement  of  the  head  is 
directly  proportional  to  the  youth  of  the  patient.  Cases  beginning  be- 
fore or  shortly  after  birth  will  present  greater  expansion  of  the 
cranial  cavity  than  such  as  have  a  later  origin.  Sometimes  some' 
sutnres  give  way  and  others  become  synostosed.  Where  sutures  are 
separated  Wormian  bones  often  form,  or  a  membranous  connection  is 
established  between  the  cranial  bones. 

Occasionally,  in  these  cases  of  primary  hydrocephalus,  the  defects  of 
brain-substance  are  not  due  to  pressure-atrophy,  but  there  is  an  associ- 
ated condition  of  malformation  or  defect.  Thus,  in  an  autopsy  of 
Bourneville's,  on  a  girl  about  thirteen  years  of  age,  with  congenital 
hydrocephalus,  idiocy,  and  epilepsy,  the  hemispheres  of  the  cerebellum 
were  totally  absent,  the  cerebellum  being  represented  by  the  vermis, 
which  was  the  size  of  a  pigeon's  egg.  Perhaps  such  a  defect  is  due  to 
a  pressure-atrophy  beginning  very  early  in  fetal  life. 

As  regards  the  pathology  of  secondary  hydrocephalus,  we  possess  more 
definite  knowledge.  In  this  the  internal  hydrocephalus  is  caused  by  ob- 
struction of  the  veins  of  Galen,  or  by  obliteration  of  the  foramina  of 
Monro,  Magenclie,  or  Mierzejewski.  Common  causes  are  tumors  of 
the  cerebellum,  such  as  sarcomata  and  tubercles.  Meningitis  may  act 
in  the  same  way.  The  amount  of  hydrocephalus,  ventricular  dilatation, 
and  expansion  of  the  skull  thus  induced  will  depend  directly  upon  the 
youth  of  the  infant  or  child.  As  a  rule,  secondary  hydrocephalus  never 
reaches  the  extent  of  the  primary  form,  owing  to  the  rapidly  fatal  nature 
of  its  cause.  In  these  cases  we  seldom  see  pressure  effects  beyond  flat- 
tening of  the  convolutions  and  moderate  expansion  of  the  cranial  vault. 

An  exceptional  and  an  extremely  interesting  case  was  one  upon  whom 
I  made  an  autopsy  at  Randall's  Island,  not  long  ago.  It  was  a  case  of 
very  marked  hydrocephalus  in  a  child  of  four  years,  in  which  a  small 
tumor  of  the  pineal  gland,  the  size  of  a  small  hazel-nut,  compressed 
and  obliterated  the  aqueduct  of  Sylvius.  Both  of  the  lateral  ventricles 
were  enormously  distended,  the  left  more  than  the  right,  and  contained 
twenty-four  ounces  of  clear  fluid.  The  third  ventricle  was  also  widely 
dilated.  The  fourth  ventricle  was  of  normal  size.  Microscopical  sec- 
tions of  the  quadrigeminal  region  revealed  the  obliteration  of  the  aque- 
duct. The  tumor  was  apparently  tubercular,  but  was  not  examined,  it 
having  been  mislaid  and  lost. 

The  cases  of  acute  hydrocephalus  due  to  meningitis  serosa,  and  the 
cases  in  which  a  defect  of  brain-substance  is  counterbalanced  by  an  equal 
bulk  of  cerebrospinal  fluid,  do  not  commonly  fall  under  this  heading. 

In  chronic  hydrocephalus  interims  there  seems  to  be  a  special  sus- 
ceptibility of  the  membranes  to  acute  disease,  so  that  at  autopsy  it  is 
not  uncommon  to  find  evidence  of  an  acute  meningitis,  simple,  hemor- 
rhagic, suppurative,  or  tubercular. 


800 


MENTAL  DISEASES. 


The  fluid  found  in  hydrocephalic  idiots  has  been  frequently  analyzed. 
In  a  case  of  Bourneville's  the  analysis  of  the  hydrocephalic  fluid,  with- 
drawn nine  hours  after  death,  resulted  as  follows  :  Color,  pale  yellow  j 
aspect,  clear  after  standing  ;  reaction,  neutral ;  odor,  like  that  of  blood  ; 
consistence,  slightly  viscous;  density,  1.006;  organic  matter,  1.65; 
salts,  10;  total  fixed  solids,  11.65;  phosphoric  acid,  0.22;  sodium 
chlorid,  0.80  ;  albumin,  0.26  ;  leukocytes,  very  few ;  red  blood-cor- 
puscles, considerable. 

In  microcephalic  idiocy  we  recognize  three  distinct  classes  : 

1.  Morphological  microcephaly,  in  which  there  are  no  pathological 
changes  in  the  brain,  but  simply  a  brain  arrested  in  its  development 
with  persistent  fetal  morphology. 

2.  Pathological  microcephaly,  in  which  the  small  size  of  the  head 
is  determined  by  morbid  processes  in  the  brain  (such  as  meningeal  hem- 
orrhage, thrombosis,  porencephalic  defects,  etc.). 

3.  Mixed  cases  of  microcephaly,  in  which  pathological  processes  are 
superadded  to  or  associated  with  true  morphological  microcephaly. 

The  following  table  gives  a  summary  of  the  pathological  conditions 
responsible  for  most  cases  of  idiocy  : 


Etiological  Factors. 

Primary  Lesions. 

Terminal  Conditions  Found 
at  Autopsy. 

Hereditary  degeneracy. 

Developmental    defects    of 
portions    of   the    brain, 
such  as  corpus  callosum, 
one  hemisphere  or  part 
of  a  hemisphere. 

Same,  with  compensatory 
hydrocephalus  internus, 
externus,  or  both  ;  com- 
pensatory thickening  of 
skull. 

Hereditary  degeneracy. 

Micrencephalus,    with     or 
without  defects. 

Same.  Brain-substance 
often  sclerotic  ;  deficient 
in  microscopical  ele- 
ments. Sometimes  com- 
pensatory hydrocephalus. 

Hereditary  degeneracy. 

Agenesis  corticalis  ;  slight 
changes  in  gross  appear- 
ance of  brain  ;  maldevel- 
opment  of  microscopical 
elements. 

Same.  Sometimes  hydro- 
cephalus externus. 

Vascular  disorders  of  fetal 
brain. 

Partial  defects  like  poren- 
cephalia, microgyria. 

Same.  Compensatory  hy- 
drocephalus and  thicken- 
ing of  the  skull ;  atrophy 
and  sclerosis  of  affected 
convolutions  or  lobes. 

Diseases  of  mother  or  trau- 
ma to  mother. 

Fetal    disorders,    such     as 
syphilis,      asphyxia      at 
birth,     prolonged     labor, 
infantile  convulsions, 
febrile  diseases  of  child, 
cerebral  diseases  of  child. 

Meningeal       hemorrhage  ; 
thrombosis  ;     embolism  ; 
cerebral        hemorrhage  ; 
meningitis ;       meningo- 
encephalitis. 

Atrophy  ;  diffuse  sclerosis  ; 
cysts  ;  meningoencepha- 
litis. 

Uncertain   fetal    and   post- 
natal causes. 

Tumor  sometimes  ;  oftener 
unknown. 

Hydrocephalus. 

Antecedent   infectious   dis- 
eases of  mother  or  child  (?). 

Tuberous  sclerosis. 

Tuberous  sclerosis. 

IDIOCY.  801 

In  amaurotic  idiocy  but  six  autopsies  have  been  made,  and  thus  far 
the  changes  found  may  be  considered  to  be  simply  degeneration  of  the 
gray  matter  of  the  cortex  and  of  the  anterior  horns  of  the  cord 
(Sachs). 1 

Diagnosis  and  Prognosis  of  Idiocy. — Diagnosis  of  Idiocy  in 
General. — It  is  seldom  difficult  to  make  a  diagnosis  of  idiocy  in  child- 
hood when  the  individual  has  reached  such  a  stage  of  development 
that  backwardness  and  deficiency  stand  out  in  prominent  contrast  to 
the  normal  average  of  intelligence  in  children  of  the  same  age.  Occa- 
sionally, however,  we  have  to  deal  with  some  species  of  insanity  in 
childhood,  in  which  case  the  matter  of  diagnosis  is  important  because 
of  the  more  favorable  outlook  for  insanity.  There  are  not  a  few  pa- 
tients cared  for  in  institutions  for  the  feeble-minded  and  idiots  in  which 
insanity  has  been  the  original  factor  in  the  mental  impairment,  and 
when  the  histories  of  such  are  obscure,  it  is  almost  impossible  to  dis- 
tinguish between  ordinary  idiocy  and  what  may  be  truly  termed  a  ter- 
minal dementia  following  upon  some  acute  insanity  of  childhood.  In 
these  cases  residual  symptoms  of  a  psychosis  can  be  our  only  guid 


The  diagnosis  of  some  form  of  idiocy  in  infancy  is  far  from  easy 
unless  one  familiarizes  himself  thoroughly  with  the  manifold  steps  of 
development  for  the  first  few  years  of  existence.  Early  diagnosis  is 
of  the  utmost  importance,  not  only  for  the  benefit  of  the  unfortunate 
child  itself,  but  on  account  of  the  deep  solicitude  of  the  parents  for  its 
future.  One  of  the  chief  aids  in  differentiation  will  be  found  in  a 
study  of  the  physical  condition  of  the  infant.  The  shape  and  size  of 
the  head  should  be  carefully  noted  and  compared  with  normal  shapes 
and  statistics.  Unfortunately,  there  are  no  elaborate  tables  of  head 
measurements  in  infants  and  children  as  yet  made  which  can  be  looked 
upon  as  a  final  establishment  of  the  normal  averages,  but  the  following 
figures  are  fairly  representative  of  cranial  measurements  : 

Circumference  at  birth 36  cm.  in  both  sexes. 

Binauricular  arc 22    "     "     "       " 

Naso-occipital  arc 22    "     "     "       " 

At  the  age  of  one  year  these  dimensions  have  increased  to — 

Circumference     44  cm.  in  both  sexes. 

Binauricular  arc 27    "     "     "        " 

Naso-occipital  arc 30    "     "     "       " 

Malformation  and  asymmetry  of  the  head  should  be  taken  into  con- 
sideration. The  various  malformations  are  treated  of  in  another  chapter. 
The  presence  of  marked  anatomical  stigmata  of  degeneration  is  of  sig- 
nificance. Paralysis  of  a  limb  or  limbs,  if  of  cerebral  origin,  is  of  great 
importance,  indicating,  as  it  does,  some  lesion  of  the  brain,  which  may 
retard  or  restrict  mental  development  and  lead  to  paralytic  or  epileptic 
idiocy,  or  both.     Some  of  the  morbid  movements,  such  as  nystagmus, 

1  "A  Case  of  Amaurotic  Family  Idiocy  with  Autopsy,"  by  Frederick  Peterson, 
M.  D  ,  "Jour.  Nerv.  and  Ment.  Dis.,"  July,  1898. 
51 


802  MENTAL  DISEASES. 

ataxia,  chorea,  or  athetosis,  may  be  present,  and,  as  symptoms  of  dis- 
order of  the  central  nervous  system,  should  lead  to  a  careful  investi- 
gation of  the  whole  mental  and  physical  organization. 

While  it  is  frequent  to  find  evidence  of  idiocy  immediately  after 
birth  in  bodily  and  especially  in  cranial  and  facial  characteristics,  yet 
after  careful  examination  as  to  imperfect  action  of  the  sensations  and 
perceptions,  we  may  sometimes  recognize  idiocy  in  cases  where  physical 
evidence  is  wanting.  The  child  may  not  learn  easily  to  take  the  breast. 
Its  cry  is  different  from  that  of  other  children.  It  cries  without 
motive.  Sometimes  there  is  congenital  blindness  or  congenital  deaf- 
ness (there  is  always  deafness  in  every  child  for  several  days  after 
birth).  In  the  normal  child  the  sense  of  smell  may  be  stimulated  im- 
mediately after  birth,  and  taste  is  evident  in  a  few  days.  In  the  idiot 
these  special  senses  may  be  retarded  in  their  development,  or  absent. 
The  movements  of  the  eyes  are  generally  irregular,  and  strabismus  is 
frequent  until  the  end  of  the  second  month  in  normal  children,  so  that 
in  the  diagnosis  of  idiocy  this  can  not  be  relied  upon  as  significant  unless 
the  eye-movements  are  imperfect  after  the  third  month.  In  the  normal 
child  the  eyes  follow  a  light  between  the  third  and  fourth  weeks  ;  in  idiots 
this  ability  may  be  retarded  indefinitely.  The  normal  child  starts  at 
gentle  touches  on  the  third  day  after  birth.  The  new-born  idiot  may  be 
immobile  or  feeble  in  its  reactions  to  cutaneous  stimuli.  The  normal 
child  laughs  at  tickling  in  the  eighth  week,  while  the  idiot  or  imbecile 
is  not  incited  to  laughter  ordinarily  at  all  in  the  earliest  years  of  life. 
From  these  facts  it  follows  that  in  defectives  we  must  examine  the  sen- 
sory organs  themselves,  so  far  as  possible,  for  defects,  as  well  as  study 
their  reactions  and  impaired  perceptions  of  sensations. 

Preyer,  in  his  work  on  '■'  The  Mind  of  the  Child,"  gives  a  conspectus 
of  the  development  of  the  normal  faculties  during  the  first  forty  months 
of  the  child's  life,  and  the  following  brief  abstract  is  made  therefrom  for 
purposes  of  comparison  with  the  mental  development  of  the  idiot : 


NORMAL  CHILD. 

First  Month. — Sensitive  to  light  as  early  as  first  and  second  days. 
Pleasure  in  light  of  candle  and  in  bright  objects  on  eleventh  day. 
Hears  on  fourth  day.  Discriminates  sounds  last  two  weeks  of  month. 
Starts  at  gentle  touches  second  and  third  days.  Sensibility  to  taste  about 
end  of  first  week.  Strong-smelling  substances  produce  mimetic  move- 
ments at  birth. 

Pleasure  first  days  in  nursing,  in  bath,  in  sight  of  objects. 

Discomfort  first  days  from  cold,  wet,  hunger,  tight  clothing. 

Smiles  on  twenty-sixth  day. 

Tears  on  twenty-third  day. 

Vowel-sounds  in  first  month. 

Memory  first  active  as  to  taste  and  smell ;  then  as  to  touch,  sight, 
hearing. 

Incoordinate  movements  of  the  eyes. 


IDIOCY.  803 

Sleeps  two  hours  at  a  time,  and  sixteen  hours  in  twenty-four. 

Reflexes  active. 

Second  Month. — Strabismus  occasional  until  end  of  month.  Recog- 
nizes human  voices;  turns  head  toward  sounds.  Pleased  with  music 
and  with  human  face.  Sleeps  three,  sometimes  five  or  six,  hours. 
Laughs  from  tickling  at  eighth  week.  Clasps  with  its  four  finger-  at 
eighth  week.  First  consonants  from  forty-third  to  fifty-first  days 
(am-ma,  ta-h,u,  go,  ara). 

Third  Month. — Sixty-first  day,  cry  of  joy  at  sight  of  mother  and 
father ;  eyelids  not  completely  raised  when  child  looks  up.  Accommo- 
dates at  ninth  week.  Notes  sound  of  watch  at  ninth  week ;  listens 
with  attention. 

Fourth  Month. — Eye-movements  perfect.  Objects  seized  are  moved 
toward  the  eyes.  Grasps  at  objects  too  distant.  Joy  at  seeing  self  in 
mirror.  Contraposition  of  thumb  in  grasping  at  fourteenth  week. 
Head  held  up  permanently.  Sits  up  with  back  supported  at  fourteenth 
week.     Beginning  to  imitate. 

Fifth  Month. — Discriminates  strangers.  Looks  inquiringly.  Pleas- 
ure in  crumpling  and  tearing  newspapers,  pulling  hair,  ringing  a  bell. 
Sleeps  ten  to  eleven  hours  without  food.  Desire  shown  by  stretching 
out  arms.     Seizes  and  carries  objects  to  mouth.     Consonants  I  and  /.-. 

Sixth  Month. — Raises  self  to  sitting  posture.  Laughs,  and  raises 
and  drops  arms  when  pleasure  is  great.  "  Crows  "  with  pleasure.  Com- 
pares image  of  father  in  mirror  with  original. 

Seventh  Month. — Astonishment  shown  by  open  mouth  and  eyes. 
Recognizes  nurse  after  four  weeks'  absence.  Sighs.  Imitates  move- 
ments of  head,  of  pursing  lips.  Averts  head  as  sign  of  refusal. 
Places  himself  upright  on  lap. 

Eighth  Month. — Astonishment  at  new  sounds  and  sights  ;  at  imita- 
tions of  cries  of  animals. 

Ninth  Month. — Stands  on  feet  without  support.  More  interest 
shown  in  things  in  general.  Strikes  hands  together  with  joy.  Shuts 
eyes  and  turns  head  away  when  something  disagreeable  is  to  be  en- 
dured. Fear  of  dog.  Turns  over  when  laid  face  downward.  Turns 
head  to  light  when  asked  where  it  is.  Questions  understood  before 
child  can  speak.     Voice  more  modulated. 

Tenth  Month. — Sits  up  without  support  in  bath  and  carriage.  First 
attempts  at  walking  at  forty-first  week.  Beckoning  imitated.  Missed 
parents  in  absence,  also  a  single  ninepin  of  a  set.  Can  not  repeat  a 
syllable  heard.  Monologue  and  hints  at  imitation  (ma,  pappa,  tatta, 
appapa,  baba,  tdtd,  pa,  rrrr  rrra). 

Eleventh  Month. — Screaming  quieted  by  "  sh."  Sitting  becomes 
habit  for  life.  Stands  without  support.  Stamps.  Syllable  correctly 
repeated.  Whispering  begins.  Consonants  b,  p,  t,  d,  m,  n,  r,  I,  g,  k, 
vowel  a  most  used,  u  and  o  rare,  i  very  rare. 

Twelfth  Month. — Pushes  chair.  Can  not  raise  self  or  walk  without 
help.     Obeys  command,  "  Give  the  hand." 

Thirteenth  Month. — Creeps.  Shakes  head  in  denial.  Says  papa 
and  mamma.     Understands  some  words  spoken. 


804  MENTAL   DISEASES. 

Fourteenth  Month. — Can  not  walk  without  support.  Raises  himself 
by  chair.     Imitates  coughing  and  swinging  of  arms. 

Fifteenth  Month. — Walks  without  support.  Laughs,  smiles,  gives 
a  kiss  on  request.     Repeats  syllables.     Understands  ten  words. 

Sixteenth  Month. — Runs  alone.      Falls  rarely. 

Seventeenth,  Eighteenth,  and  Nineteenth  Months. — Sleeps  ten  hours 
at  a  time.  Associates  words  with  objects  and  movements.  Blows 
horn,  strikes  with  hand  or  foot,  gives  leaves  to  stag,  waters  flowers,  puts 
stick  of  wood  in  stove,  washes  hands,  combs  and  brushes  hair,  and 
other  imitative  movements. 

Twentieth  to  Twenty-fourth  Month. — Marks  with  pencil  on  paper, 
whispers  in  reading  newspaper.  Very  few  expressions  of  his  are  recog- 
nizable. Executes  orders  with  surprising  accuracy.  Tries  to  sing  and 
beat  time,  and  dance  to  music. 

Twenty-fifth  to  Thirtieth  Month. — Distinguishes  colors  correctly. 
Sentences  of  several  words.  Begins  to  climb  and  jump  and  to  ask 
questions. 

Thirtieth  to  Fortieth  Month. — Goes  upstairs  without  help.  Sen- 
tences correctly  applied.  Clauses  formed.  Words  distinctly  spoken, 
but  influence  of  dialect  appears.  Questioning  repeated  to  weariness. 
Approximates  manner  of  speech  to  that  of  family  more  and  more. 

By  contrasting  the  mental  development  of  the  supposedly  abnormal 
child  with  these  observations  of  Preyer  upon  normal  development,  it  will 
not  be  difficult  to  appreciate  impairment  of  varying  degree.  The  presence 
of  mere  backwardness  may  not  infrequently,  however,  be  observed  in  chil- 
dren that  later  develop  normally,  and  it  is  well  to  bear  this  fact  in  mind  ; 
but  the  combination  of  backwardness  in  the  development  of  the  sen- 
sations, perceptions,  ideation,  and  speech  with  marked  physical  signs  of 
degeneracy  or  brain  lesion  would  be  naturally  of  the  greatest  importance 
from  the  diagnostic  point  of  view. 

Diagnosis  of  the  Form  and  Nature  of  the  Idiocy. — While  the 
diagnosis  of  the  presence  of  idiocy  is,  as  a  rule,  fairly  easy,  especially 
after  infancy  has  reached  the  stage  of  childhood,  the  diagnosis  of  the 
type  or  kind  of  idiocy  presented  is  often  attended  with  great  difficulty. 
Where  the  cerebral  disorder  or  defect  is  accompanied  by  striking  physi- 
cal peculiarities  or  malformations,  such  as  hydrocephalus,  microceph- 
aly, paralysis,  or  myxedema,  we  are  immediately  in  a  position  to 
classify  the  type.  In  idiocy  associated  with  epilepsy,  too,  we  can  readily 
approximate  the  type,  though  it  must  always  be  remembered  that  there 
are  three  distinctive  ways  in  which  epilepsy  and  idiocy  are  correlated — 
viz.,  paralytic  idiocy  combined  with  epilepsy,  epileptic  idiocy  from  a 
homologous  lesion  not  implicating  the  motor  centers  or  tracts,  and, 
finally,  dementia  in  childhood  depending  upon  the  epilepsy.  The  trau- 
matic class  of  cases  is  recognized  either  by  the  external  evidence  of  in- 
jury to  the  skull  or  by  the  history  of  direct  relation  of  the  psychic 
symptoms  to  the  antecedent  trauma.  The  sensorial  type  of  idiocy  is 
distinguished  by  existing  or  foregone  loss  of  two  or  more  senses,  par- 
ticularly blindness  and  deafness.  The  amaurotic  type  presents  a  char- 
acteristic syndrome — viz.,  flaccid  or  spastic  weakness  or  paralysis  of  the 


IDIOCY.  805 

whole  musculature,  diminished  or  exaggerated  tendon-reflexes,  dis- 
tinctive changes  in  the  fundus  leading  to  optic  atrophy,  and  marasmus. 
In  the  majority  of  cases,  then,  Ave  arc  in  a  position  to  determine  readily 
the  form  of  idiocy  presented  by  the  patient  and  to  formulate  an  opinion 
as  to  the  nature  of  the  pathological  process  or  the  condition  underlying 
it;  but  there  will  still  remain  a  considerable  number  of  cases  in  which 
diagnosis  can  not  be  made  during  life,  cither  as  to  the  type  of  idiocy 
before  us  or  as  to  the  character  of  the  process.  Among  such  puzzling 
cases  will  be  those  indistinguishable  from  the  psychoses  of  early  life; 
idiocy  following  meningeal  hemorrhage  and  meningitis  without  inducing 
either  paralysis  or  epilepsy  ;  idiocy  due  to  tuberous  sclerosis,  and  the 
like. 

Diagnosis  of  the  Degree  of  Idiocy. — It  is  necessary,  for  purposes 
of  medicopedagogical  treatment,  to  comprehend  the  degree  of  idiocy, 
not  only  to  determine  whether  it  is  simple  idiocy,  imbecility,  or  feeble- 
mindedness, but  to  ascertain,  as  far  as  possible,  the  different  shades  of 
each  of  these  ;  and  it  is  useful,  too,  to  watch  the  progress  of  a  case  under 
treatment,  and  to  record  from  time  to  time  the  advance  made  by  the 
patient  and  pupil.  Accordingly,  the  writer  has  drawn  up  what  may  be 
termed  a  species  of  mind  chart,  as  given  opposite.  The  physician  will  be 
familiar  with  the  ordinary  tests  for  common  and  special  sensibilities. 
The  intensity  and  duration  of  attention  may  be  studied,  in  the  same 
connection,  by  methods  which  will  readily  suggest  themselves  in  relation 
to  objects,  colors,  sounds,  smells,  and  tastes,  which  are  utilized  in  such  a 
way  as  to  demonstrate  perception,  the  retention  of  the  perception,  and 
the  duration  of  such  retention.  The  chief  difficulty  will  be  in  deter- 
mining and  recording  the  purely  intellectual  features  of  the  case  ;  but 
some  patience  and  perseverance  will  demonstrate  the  ability  and  degree 
of  ability  of  the  patient  to  acquire,  conserve,  associate,  and  produce 
ideas,  concrete  and  abstract ;  to  appreciate  resemblances  and  differences  ; 
to  count,  add,  subtract,  and  divide. 

Prognosis. — As  regards  the  cure  of  idiocy,  there  can  not  be  any 
difference  of  opinion.  There  are  few  cases — indeed,  almost  no  case — in 
which  improvement  to  some  degree  may  not  be  promised  under  proper 
conditions  ;  but  cure  there  is  none.  The  profound  idiot  may  be  regen- 
erated to  some  slight  degree  ;  be  made  less  repulsive,  less  offensive,  less 
destructive.  The  imbecile  can  be  taught  cleanliness,  speech,  divers 
occupations.  The  feeble-minded  subject  is  susceptible  of  enormous  im- 
provement. It  is  impossible  in  any  case  to  predict  how  much  advance 
may  be  made  under  the  best  supervision,  but  it  will  be  safe  to  say  that 
the  methods  now  in  vogue  in  the  training  of  the  idiot  will  surprise  the 
relatives  or  guardians  by  their  efficacy,  and  there  is  no  case  so  unprom- 
ising and  hopeless  as  to  contraindicate  an  attempt  at  improvement. 
Left  to  itself,  even  a  mild  type  of  idiocy  will  not  only  make  no  prog- 
ress, but  will  be  certain  to  degenerate,  to  lapse  into  a  lower  grade. 
Shuttleworth, x  in  reviewing  the  results  of  twenty  years'  experience  at 
one  of  the  large  English  institutions,  states  that  of  patients  discharged 

1  Tuke's  "  Dictionary  of  Psych.  Med.,"  p.  675. 


806 


MENTAL  DISEASES. 


Mind  Chart. 

Name Age '. Sex 

Constitution  (feeble,  fair,  robust,  or  obese) 

Form  of  idiocy Degree  of  idiocy 

Paralysis,  deformity,  or  morbid  movements 

Right-  or  left-handed Temperament  (cheerful,  gloomy,  restless, 

sluggish,  etc.) 


Sense 
defects. 

Sight. 

Hearing. 

Taste. 

Smell. 

Tactile 
and  pain. 

Muscu- 
lar. 

Ther- 
mic. 

Intensity 
and  duration 
of  attention. 

Instincts. 

Hunger. 

Self-pres- 
ervation. 

Sleep. 

Voluntary 
move- 
ments ; 
play. 

Sexual. 

Imita- 
tion. 

Morals  and 
Habits. 

Tidiness. 

Destruc- 

tiveness. 

Human- 
ity. 

Veracity. 

Polite- 
ness. 

Obedi- 
ence. 

Sentiments. 

Pleasure 
and  pain. 

Affec- 
tion. 

Fear. 

Anger. 

Acquisi- 
tiveness. 

Shame. 

Curios- 
ity and 
astonish- 
ment. 

Language. 

Speech. 

Eeading. 

Writing. 

Gesture. 

Drawing. 

Intellect. 

Ideas. 

Memory. 

Associa- 
tion of 
ideas. 

Reason. 

Judg- 
ment. 

Will. 

Arith- 
metic. 

Special  aptitudes . 


IDIOCY.  .SO  7 

therefrom  after  full  training,  10  percent,  became  self-supporting,  another 

10  per  cent,  might  have  become  so  had  they  obtained  suitable  situations, 
and  about  20  per  cent,  were  reported  as  useful  to  their  friends  al  home. 
This  bears  out  the  earlier  estimate  of  Seguin,  who  said  that  "  more  than 
40  per  cent,  have  become  capable  of  the  ordinary  transactions  of  life 
under  friendly  control,  of  understanding  moral  and  social  abstraction.:, 
of  working  like  two-thirds  of  a  man  ;  and  2o  to  30  per  cent,  come 
nearer  and  nearer  the  standard  of  manhood,  until  some  of  them  will  defy 
the  scrutiny  of  good  judges,  when  compared  with  ordinary  young  men 
and  women." 

There  are  certain  features  in  connection  with  the  different  types  of 
idiocy  which  are  helpful  in  forming  our  opinion  as  to  the  probable 
future  of  a  patient.  For  instance,  it  may  be  taken  as  an  axiom  that 
the  greater  the  defect  or  injury  of  the  brain,  the  profounder  will  be  the 
mental  impairment  and  the  more  difficult  will  be  the  labor  of  bringing 
about  an  amelioration  of  the  condition.  The  earlier,  too,  that  the  brain 
is  hampered  in  its  development,  the  worse,  as  a  rule,  is  the  prognosis. 
This  holds  good  for  every  form  of  idiocy.  Hence  the  outlook  for  the 
congenital  types  is  less  promising  than  that  for  the  acquired,  and  for 
idiocy  acquired  in  the  first  year  less  than  that  for  idiocy  acquired  in  the 
second.  Some  of  the  prognostic  indications  of  the  special  forms  will 
be  discussed  under  their  respective  captions ;  but,  in  general,  it  may 
be  assumed  that  microcephalic  idiocy  and  congenital  hydrocephalic 
and  paralytic  idiocy  will  be  benefited  least  among  the  types  of  idiocy 
discussed,  and  always  in  proportion  to  the  intensity  of  the  morbid  pro- 
cess. The  sensorial,  traumatic,  and  myxedematous  forms  are,  ceteris 
paribus,  among  the  most  promising.  The  amaurotic  form  is  generally 
fatal.  Idiots  with  special  aptitudes,  or  idiots  savants,  tend  to  early 
psychic  degeneration.  Idiots  that  are  extremely  restless,  as  shown  by 
incessant  motion  of  the  hands,  arms,  head,  trunk,  or  by  constant  walk- 
ing, are  generally  among  the  most  intractable,  because  of  the  difficulty 
of  fixing  their  attention. 

Although  there  is  scarcely  ever  to  be  encountered  an  idiot  in  whom 
improvement  of  some  kind  can  not  be  brought  about  by  assiduous  cul- 
tivation of  whatever  residual  faculties  and  functions  he  possesses,  it  is 
practically  necessary  to  classify  idiots  into  teachable  and  unteachable. 
It  is  practically  so  because  a  majority  of  these  defectives  are  found 
among  the  poor,  who  can  not  command  all  that  the  world  affords  in  the 
way  of  treatment,  care,  and  training.  INTor  could  the  commonwealth 
assume  the  enormous  task  of  doing  the  best  for  all  its  idiot  charges.  No 
community  could  possibly  be  repaid  for  any  such  undertaking,  because 
the  idiots  classified  by  public  authorities  as  unteachable  are  not  sus- 
ceptible of  such  development  as  would  satisfy  the  tax-payers'  right  to 
ask  the  utility  of  the  expenditure.  It  is  only  with  private  families  that 
anxious  parental  solicitude  will  and  can  demand  that  medicopedagog- 
ical  care,  skill,  and  patience  which  can  surmount  almost  insuperable 
difficulties  in  the  education  of  profound  idiots.  Practically,  therefore, 
we  find  that  there  is  a  tendency  to  separate  idiots  into  the  teachable 
and  unteachable  ;  a  tendency  in   our  public  institutions  to  exclude  un- 


808  MENTAL  DISEASES. 

promising  cases,  such  as  epileptic  and  paralytic  idiots,  idiots  with  mal- 
formations, marked  cases  of  hydrocephalus  and  microcephaly,  and,  indeed, 
any  patient  requiring  that  particular  and  assiduous  care  which  it  is  not 
in  the  power  of  the  commonwealth  to  give. 

The  prognosis  as  regards  life  depends  directly  upon  the  degree  of 
injury  to  or  defect  of  the  brain.  In  general,  idiots  are  short-lived. 
Diplegic  and  paraplegic  idiots  seldom  attain  the  age  of  twenty  years  ; 
hemiplegic  idiots  may  live  much  longer,  though  it  is  infrequent  for 
them  to  attain  the  age  of  forty  and  more  years ;  hydrocephalics  perish 
still  earlier.  The  same  is  true  of  profound  cases  of  microcephalic  and 
myxedematous  idiocy.  The  rare  form  known  as  amaurotic  idiocy  is 
almost  invariably  fatal  in  infancy. 

General  Treatment  of  Idiocy. — The  treatment  of  the  idiot  in- 
volves the  employment  of  both  physician  and  teacher.  The  adjective 
medicopedagogic  is  made  use  of  to  designate  this  combination  of  medi- 
cal and  educational  features  for  the  care  of  the  defective  classes.  In 
the  union  of  the  two  professions  for  such  purpose  the  educator  occupies 
relatively  the  higher  and  more  important  position.  The  inestimable 
services  of  trained  care-takers  or  nurses  are  not  to  be  overlooked.  That 
patient  will  profit  most  who  receives  the  properly  combined  aid  of  the 
best  physician,  best  teacher,  and  best  nurse.  As  a  rule,  this  fortunate 
concurrence  of  necessary  aids  is  more  apt  to  be  found  in  the  public  or 
private  institution  than  in  the  home ;  but  that  it  is  possible  to  carry  on 
treatment  at  home  under  favorable  circumstances,  is  not  to  be  gainsaid. 

The  methods  of  procedure  formulated  by  Itard,  expanded  by  Seguin, 
and  employed  now-a-days  everywhere  in  private  and  public  institutions 
for  idiots,  with  modifications  induced  by  experience  and  the  progress 
of  educational  science,  are  well  described  in  the  writings  of  Bourneville, 
Shuttleworth,  Ireland,  Down,  and  others.  A  brief  resume  is  given 
below  of  the  process  of 

Education  of  Idiots. — The  educational  treatment  should  begin  as 
soon  as  the  diagnosis  of  defective  intelligence  is  made.  It  need  not  be 
pushed  vigorously  at  too  early  an  age  ;  but  infancy,  when  the  nervous 
system  is  most  impressionable,  plastic,  and  pliable,  is  the  time  for  easy 
modification  and  the  bringing  out  of  the  rudimentary  psychic  processes 
which  are  the  foundations  for  the  later  conduct,  habits,  intelligence, 
and  speech.  Patients  are  admitted  to  the  Bicetre  and  Salpetriere  at 
the  age  of  two  years  and  over. 

In  order  to  understand  the  methods  of  pedagogic  treatment  of  idiocy, 
let  us  imagine  an  infant  brought  before  us  afflicted  with  a  profound  degree 
of  idiocy — 1.  e.,  one  showing  little  or  no  attention,  unable  to  walk,  to  use 
its  hands  or  to  speak,  and  uncleanly  in  habits.  In  undertaking  a  case 
of  this  kind  the  process  of  education  is  pursued  with  the  following  dis- 
tinct purposes  in  view  : 

1 .  To  develop  the  attention  and  sharpen  the  five  senses. 

2.  To  develop  coordinated  movements  and  strengthen  the  muscles. 

(a)  To  teach  to  walk. 

(b)  To  teach  use  of  the  hands. 

3.  To  inculcate  habits  of  cleanliness  in  person  and  dress. 


IDIOCY.  809 

4.  To  teach  the  patient  the  use  of  language. 

■5.  To  arouse  the  intellect  hy  inculcating  ideas  of  length,  weight,  surface,  solids, 

form,  number. 
'6.  Finally,  to  carry  the  education  higher,  by  means  of  studies  in  natural  history  ami 

all  sorts  of  manual  and  industrial  and  moral  training. 

Naturally,  some  of  these  purposes  are  attained  at  the  same  time  to 
a  considerable  degree  by  some  one  process  employed  in  education. 
Thus,  when  a  light  bean-bag  is  thrown  at  the  face  of  our  patient,  the 
attention  and  sensibility  may  be  so  feeble  that  it  is  not  noticed  at  first. 
By  frequent  repetition  attention  is  developed,  sensibility  becomes  more 
acute,  a  reflex  movement  to  ward  off  the  missile  is  aroused,  and  gradu- 
ally, by  successive  stages,  the  patient  learns  to  catch  the  bag,  to  throw 
it  back,  and,  finally,  to  go  through  a  simple  drill  with  it,  accompanied 
by  music.  This  single  experiment  then  improves  the  attention  and 
several  of  the  senses,  and  aids  in  developing  coordination  and  strength 
of  the  muscles. 

Attention. — The  degree  of  attention  is,  in  the  idiot,  an  indication 
of  the  degree  of  idiocy.  To  a  certain  extent  the  degree  of  attention 
noted  is  of  value  in  prognosis ;  for,  if  the  attention  can  not  be  aroused 
at  all,  no  progress  in  education  can  be  made.  Thus  the  first  step  in 
our  process  of  education  must  be  the  employment  of  methods  of  excit- 
ing attention.  The  most  useful  are  such  as  appeal  to  cutaneous  sensi- 
bility, to  the  eye,  and  to  the  ear.  But  even  if  these  are  in  abeyance, 
the  other  senses  afford  useful  avenues  of  approach  to  the  nervous 
centers.  Pricking,  tickling,  light  blows,  hot  and  cold  articles,  etc., 
may  be  used  to  attract  attention  through  the  skin.  Colored  balls, 
brilliant  pieces  of  cloth,  a  ray  of  light  in  a  dark  room,  the  magic 
lantern,  or  a  spectrum — such  things  may  be  variously  and  patiently 
experimented  with  to  fix  the  attention  of  the  eye.  A  loud  call,  a  bell, 
music,  a  gong,  or  even  a  pistol  shot  sometimes,  are  devices  for  exciting 
the  attention  of  the  ear.  Not  infrequently  months  of  patient  experi- 
ment must  be  traversed  before  we  are  rewarded  for  our  labors. 

Education  of  the  Sense  of  Touch. — The  methods  in  vogue  for 
developing  the  sense  of  touch  generally  aid  at  the  same  time  the  coordi- 
nation of  muscular  movements  ;  hence  in  actual  practice  the  education 
of  the  hand  and  touch  and  also  of  the  eye  proceed  more  or  less  simul- 
taneously. 

The  idea  of  temperature  is  developed  by  plunging  the  hand  into  cold, 
tepid,  or  warm  water,  or  by  the  application  of  bottles  containing  water 
at  different  temperatures. 

The  sense  of  smoothness  or  roughness  of  surface  is  inculcated  by 
passing  the  finger-tips  over  a  board,  one-half  of  which  is  covered  with 
velvet,  the  other  half  roughened  like  a  grater.  Pieces  of  stuff  of  vary- 
ing degrees  of  roughness  or  smoothness  are  also  made  use  of.  The 
softness  and  hardness  of  objects  are  taught  by  the  handling  of  different 
objects,  such  as  hard  balls  or  cushions. 

The  child  is  taught  to  button  by  means  of  two  bands  of  cloth,  one 
with  large  buttons  and  the  other  with  large  button-holes  ;  to  lace  up  a 
shoe,  by  means  of  a  shoe  with  eyelets  a  centimeter  in  diameter,  and 


810  MENTAL   DISEASES. 

alternately  hemmed  with  red  and  blue  leather ;  to  tie  knots,  with  the 
aid  of  a  pad  upon  which  are  spread  strings  of  divers  colors. 

Stringing  beads  and  buttons,  sticking  pins  into  a  pincushion  covered 
with  dotted  stuff,  and  the  use  of  the  size-board  and  form-board  are 
useful  means  of  developing  tactile  sense,  educating  the  eye,  and  bringing 
out  some  of  the  faculty  of  calculation. 

The  Education  of  the  Eye. — After  the  physician  has  remedied  any 
existing  visual  defects,  it  becomes  the  duty  of  the  instructor  to  interest 
the  restless  and  inattentive  eye.  As  already  mentioned,  the  attention  is 
aroused  by  glittering  and  striking  objects,  and,  once  the  gaze  is  captured, 
the  latent  sense  may  be  drawn  out  by  many  devices  familiar  to  the 
kindergartner  and  teacher.  Particolored  balls,  variegated  shapes  and 
colors  of  blocks,  spheres,  squares,  cubes,  illuminated  pictures,  gaudy 
stuffs,  the  spectrum,  the  kaleidoscope — all  of  these  play  a  role  in  the 
education  of  the  vision  of  the  defective  pupil.  The  matching  of 
ribbons,  wools,  or  cards,  and  the  discrimination  of  forms  of  blocks,  are 
methods  of  aiding  the  higher  development  of  the  visual  sense.  The 
size-  and  form-boards  already  alluded  to,  and  the  use  of  graduated  rods 
to  be  placed  by  the  pupil  in  step-like  rows,  are  excellent  adjuncts. 
Later  on  come  into  play  various  games, — dominoes,  ball,  croquet,  mar- 
bles, bean-bag,  hoops,  tennis,  skipping,  battledore  and  shuttlecock,  quoits, 
golf,  and  the  like, — in  the  employment  of  all  of  which  not  only  is  the 
vision  stimulated  and  improved,  but  there  is  a  gain  in  manual  dexterity, 
and  an  associated  development  of  some  of  the  psychic  functions.  The 
teacher  acquires  a  special  tact  in  leading  the  pupil  to  concentrate  his 
mind  upon  what  is  being  done,  and  in  making  use  of  the  instinct  of 
imitation,  so  that  the  child  endeavors  to  do  as  the  other  pupils  are  doing 
or  to  follow  the  movements  of  the  instructor. 

Education  of  the  Sense  of  Hearing1. — After  the  physician  has 
made  sure  that  defective  hearing  is  due  rather  to  want  of  attention  than 
to  any  of  the  many  causes  of  deafness,  the  teacher  experiments  upon 
the  sense  with  sounds  of  various  kinds — gongs,  bells,  speech,  instru- 
mental music,  and  songs — and  by  some  one  of  these  means  the  ear  will 
at  last  be  reached  and  kept  open  until  it  becomes  an  avenue  for  im- 
pressions from  the  environment  to  travel  to  the  brain  for  registration  and 
the  rousing  of  new  cerebral  activities.  This  organ  in  the  defective  is 
often  especially  alive  to  the  influences  of  melody  and  harmony,  to  songs 
and  jingles  and  rimes.  Music  is  an  efficient  aid  in  the  various  drills 
and  games  made  use  of  later  on  in  the  child's  mental  development. 

Education  of  the  Taste  and  Smell. — While  these  senses  have 
not  the  importance  of  the  three  just  described,  it  is  still  useful  to 
stimulate  and  develop  them  as  far  as  possible.  The  child  can  be  taught 
to  discriminate  between  the  simple  taste  sensations — salt,  sweet,  bitter, 
and  sour — by  means  of  solutions  of  salt,  sugar,  quinin,  and  citric  acid, 
and  between  odors  that  are  noisome  and  odors  that  are  pleasant  by 
means  of  tinctures  of  asafetida,  cloves,  and  musk,  and  divers  perfumes. 
Later,  he  learns  to  distinguish  flavors,  and  to  associate  what  is  good 
and  useful  with  pleasant,  and  what  is  hurtful  with  noxious  tastes  and 
smells. 


IDIOCY.  811 

Teaching  to  Walk. — A  course  of  light  massage  of  the  lower  ex- 
tremities, together  with  exercise  of  the  joints  in  flexion  and  extension, 
is  undertaken  for  the  purpose  of  developing  suppleness  and  strength  and 
improving  the  nutrition.  The  child  is  then  regularly  placed  in  a  swing 
constructed  for  the  purpose,  with  a  vertical  board  in  front  in  such  a 
position  as  to  receive  the  advancing  feet  of  the  child  as  it  moves  to  and 
fro.  The  impact  of  the  feet  upon  the  board,  with  the  backward  swing 
caused  thereby,  in  the  course  of  time  gives  the  child  a  sort  of  pleasure, 
and  awakes  in  it  a  sense  of  the  dependence  of  its  movement  upon  the 
varying  pressure  and  impact  of  its  feet.  It  is  not  long  before  the  child 
is  enabled  to  use  its  legs  with  considerable  ease  and  skill  in  the  exercise. 
Having  attained  this  stage,  the  child  is  now  frequently  held  upright  on 
its  feet  and  then  placed  between  the  parallel  bars  sustained  by  its  arms, 
in  which  position  it  is  induced  to  make  efforts  at  walking,  at  first  for  a 
few  minutes,  but  with  gradual  increase  of  the  time  of  stay  each  day. 
Then  the  pupil  becomes  quickly  ready  for  a  wheel-chair,  which  is  merely 
a  modification  of  the  principle  of  the  parallel  bars,  the  supports  being 
on  wheels,  so  that  as  the  child  walks  it  moves  the  apparatus  about  with 
it.  Later  on  it  is  taught  to  mount  and  descend  a  stair  by  means  of  a 
short,  stationary  step-ladder.  After  this  the  gait  is  rapidly  improved 
by  a  variety  of  exercises,  drills,  simple  dances,  and  the  like. 

Education  of  the  Hands. — Even  though  the  motions  of  the  hands 
be  incoordinate  and  without  force,  though  the  infant  may  be  unable  to 
do  anything  for  itself,  even  to  grasp  an  object  or  to  oppose  the  thumb 
to  the  fingers,  there  are  many  methods  of  overcoming  such  defects  and 
developing  the  normal  power  and  usefulness  of  the  hands.  Among  these 
is  the  employment  of  the  parallel  swinging-ladders  and  rings.  At  first 
the  child's  hands  are  applied  to  the  rounds  and  held  there  by  the  teacher 
during  the  execution  of  such  movements  as  standing,  sitting  down, 
raising  the  arms  high  above  the  head,  and  bending  forward  and  back- 
ward, swinging  to  and  fro,  and  so  on. 

As  the  pupil  makes  progress,  the  drill  is  carried  on  with  great  reg- 
ularity and  precision,  accompanied  by  spoken  commands  and  often  with 
music.  In  this  way  not  only  are  the  muscles  strengthened  and  coordi- 
nated and  the  use  of  the  hands  and  feet  perfected,  but  a  familiarity 
with  certain  words  and  ideas  and  their  association  is  created. 

The  use  of  blocks  in  building  up  various  structures,  with  the  subse- 
quent pleasure  of  tumbling  them  down  again,  is  as  useful  to  these  defec- 
tives as  to  normal  infants. 

Finger-exercises  with  the  peg-board,  or  by  means  of  picture-perforat- 
ing, as  practised  in  the  kindergarten,  may  come  into  play  for  the  devel- 
opment of  the  finger  movements  of  the  hand.  Some  of  the  apparatus 
employed  in  educating  the  sense  of  touch  are  equally  valuable  for  train- 
ing the  accurate  movements  of  the  hands. 

Teaching'  Habits  of  Cleanliness  in  Person  and  Dress. — Idiots 
of  every  degree  are  slovenly,  awkward,  negligent,  unless  taught  and 
supervised,  and  the  lower  grades  are  incompetent  to  use  spoon,  knife,  or 
fork,  unable  to  care  for  themselves  in  any  way,  and  continually  drooling, 
sucking  their  fingers,  holding  the  mouth  open,  and  wetting  and  soiling 


812  MENTAL  DISEASES. 

themselves.  It  is  of  paramount  importance,  then,  in  their  education  to 
make  every  effort  to  overcome  these  deficiencies. 

Such  children  as  are  unable  or  just  learning  to  walk  are  placed  by 
day  in  especially  constructed  chairs,  and  by  night  in  especially  prepared 
beds,  for  purposes  of  cleanliness,  and  must  be  watched  and  raised  at 
certain  hours  by  the  nurses.  It  is  surprising  how  many  will,  by  assidu- 
ous attention,  soon  learn  to  give  some  signal  to  the  care-takers  of  their 
needs,  and  in  the  end  acquire  control  over  themselves  in  this  regard. 
They  learn  to  expect  the  regular  bath,  and  those  who  progress  further 
become  systematic  in  ablutions,  cleansing  the  teeth,  and  all  the  little 
matters  pertaining  to  the  toilet.  At  the  table  they  are  taught  first  the 
use  of  the  spoon,  then  of  the  fork,  and  lastly  of  the  knife.  They  learn 
to  dress  themselves  and  to  make  themselves  neat  and  tidy,  and  ulti- 
mately to  brush  and  arrange  their  clothing,  blacken  their  shoes,  make 
their  beds,  etc.  All  of  this  instruction  requires  time  and  the  utmost 
perseverance  and  patience  on  the  part  of  the  attendants.  By  it  we 
also  train  the  hands,  the  senses,  and  the  intellect. 

To  close  the  mouth  and  prevent  drooling,  faradic  electrization  of  the 
orbicularis  oris  is  employed,  and  the  insertion  of  a  flat  piece  of  wood 
or  a  stick  of  licorice-root  in  the  mouth  is  useful.  The  teeth  need 
careful  looking  over  by  a  dentist  from  time  to  time,  and  daily 
cleansing.  Sucking  of  the  fingers  and  biting  of  the  nails  can  be 
overcome  by  application  of  aloes  and  other  bitter  or  disagreeable 
substances. 

The  Teaching  of  Language. — In  idiots  we  must  begin  our  incul- 
cation of  the  uses  of  language  according  to  the  laws  of  its  evolution  in 
the  normal  child,  first,  however,  correcting  such  defects  in  the  ear, 
mouth,  or  vocal  apparatus  as  are  amenable  to  medical  or  surgical  treat- 
ment. A  child  first  develops  its  auditory  word-center  and  then  the 
motor  speech-center.  These  two  centers,  with  an  association  tract,  are 
the  primitive  basis  of  language  in  the  child.  Often,  in  defective 
children,  a  course  of  gymnastic  exercises  of  the  lips,  tongue,  and  jaw 
will  be  a  necessary  adjunct  to  the  instruction,  and  in  cases  of  deafness 
the  lip-imitation  method  of  education  will  require  to  be  used. 

In  developing  the  motor  speech-center  the  child  begins  by  repeating 
the  simplest  Unguals  and  labials,  such  as  "  dadda,"  "  tatta,"  "  mamma," 
"  papa,"  and  "  babba,"  and  these  first  consonants  should  be  employed  in 
the  construction  of  the  new  words  to  be  learned. 

Music  is  an  excellent  auxiliary  in  teaching  the  articulation  and  use 
of  words,  and  Shuttleworth  recommends  Elliott's  "  National  Nursery 
Rimes,"  set  to  pleasing  melodies,  as  particularly  adapted  for  the  pur- 
pose. The  interest  of  the  pupil  is  often  best  secured  and  sustained 
by  the  employment  of  objective  illustrations.  The  naming  of  subjects 
of  pictures,  of  persons  and  things  about  the  room,  of  parts  of  the 
body,  and  the  imitation  of  cries  of  animals,  are  means  of  arousing 
interest. 

After  developing  the  word-hearing  and  the  motor  speech  centers, 
the  visual  and  writing  centers  will  require  education,  and  the  methods 
in  vogue   are  analogous   to  those   of  the   kindergarten.      Bourneville 


IDIOCY.  813 

recommends  the  use,  first,  of  black  letters  twelve  centimeters  high  ;  then 
sin  alphabet  with  the  consonants  in  black  and  the  vowels  in  red,  the 
letters  six  centimeters  in  height;  then  letters  of  ordinary  size ;  and, 
finally,  the  repetition,  in  chorus,  of  letters  and  words  placed  before  a 
class.  This  collective  exercise,  in  which  imitation  plays  a  great  part, 
contributes  markedly  to  the  development  of  speech.  Figures  are 
employed  in  much  the  same  manner,  and  counting  is  learned  from 
some  of  the  various  apparatus  already  described,  as  well  as  from 
simpler  and  more  interesting  devices,  such  as  the  use  of  the  fingers, 
shells,  marbles,  buttons,  beads,  and  the  abacus.  The  nursery  game  of 
keeping  shop  is  especially  useful  for  developing  the  ideas  of  number, 
weights,  and  values. 

Writing  and  drawing  are  taught  by  means  of  sand-boxes,  blackboard 
exercises,  and,  finally,  drawing-books.  The  knowledge  of  form  is  best 
inculcated  by  modeling  in  clay,  and  by  reproductions  in  clay  or  wood 
of  surface  drawings. 

From  these  primary  lessons  it  is  but  a  step  to 

Manual  and  Industrial  Training-. — When  the  pupil  has  reached  a 
certain  stage  of  mental  development,  every  effort  is  made  to  further 
the  training  to  such  an  extent  as  to  subserve  the  demands  of  health  and 
utility.  Methods  of  manual  and  industrial  education  are  best  furthered 
in  institutions  in  which  every  variety  of  occupation  commensurate  with 
the  individual  needs  and  tastes  of  the  pupils  can  be  satisfactorily  carried 
out.  In  most  existing  institutions  it  is  true  that  the  ideal  system  of 
care  and  development  of  defectives  has  not  yet  been  attained,  but  the 
tendencies  of  the  present  time  are  in  the  right  direction.  The  insti- 
tutions of  the  future  for  all  classes  of  dependents,  for  idiots,  for  the  in- 
sane, and  for  the  inmates  of  prisons  and  reformatories,  will  doubtless  be 
modeled  on  the  colony  plan.  They  will  be  village  settlements  or  com- 
munities wherein  the  chief  industries  will  be  such  as  relate  to  the 
housing,  clothing,  feeding,  etc.,  of  their  inhabitants,  thus  bringing  into 
existence  all  of  the  occupations  which  tend  to  utility  and  economical 
administration.  The  scheme  is  well  exemplified  and  successfully  dem- 
onstrated by  the  evolution  of  the  Craig  Colony  for  Epileptics  at 
Sonyea,  N.  Y.  Were  I  called  upon  to  draw  up  an  outline  of  a  plan  for 
a  colony  for  idiots,  it  would  be  somewhat  as  follows  : 

1.  In  the  first  place,  there  should  be  an  abundance  of  land,  at  least 
an  acre  for  each  inhabitant.  The  site  should  be  selected  with  due 
regard  to  fertility  of  soil ;  for  agriculture,  stock-raising,  and  gardening 
should  afford  employment  for  the  majority  of  the  pupils. 

2.  Convenience  of  access  to  managers  and  patients  and  their  friends 
is  a  desideratum. 

3.  In  the  construction  and  arrangement  of  buildings  the  country- 
village  idea  should  never  be  lost  sight  of,  and  the  farmstead  group — 
the  cottages,  villas,  schools,  shops,  and  so  on — should  be  simple,  inde- 
pendent, homelike,  and  surrounded  by  their  own  little  gardens,  hedges, 
etc.,  in  conformity  with  such  design. 

4.  So  far  as  possible,  each  house  should  constitute  a  home  circle, 
the  number  of  members  being  limited  to  ten  or  fifteen. 


814  MENTAL  DISEASES. 

5.  An  administration  building,  a  small  hospital  for  the  sick,  special 
villas  for  the  infirm,  bed-ridden,  ineducable,  and  disturbed  classes,  a 
gymnasium,  a  library,  a  museum,  and  swimming-  and  rain-bath,  are 
among  the  separate  structures  required  in  addition  to  those  already 
mentioned. 

6.  The  educational  features  of  the  colony  will  be  carried  on  in  ordi- 
nary schools,  Sloyd  schools,  trade  schools,  and  so  on,  and  everything 
that  may  contribute  to  the  furtherance  of  mental  development  should 
be  encouraged.  Thus  the  field  study  of  natural  history  is  one  of  the 
most  satisfactory  means  of  arousing  the  intelligence,  interest,  and  activity 
of  the  pupils.  Trees,  garden  produce,  and  flowers  should  be  labeled 
with  their  names,  botanical  and  zoological  gardens  should  be  estab- 
lished, and  the  collection  of  rocks,  leaves,  plants,  insects,  birds,  etc., 
made  a  part  of  the  system. 

7.  In  developing  the  industries  of  the  colony,  such  should  first  be 
instituted  as  will  serve  economical  purposes.  The  aim  should  be  to 
produce  most  of  the  foodstuffs  required,  to  carry  on  domestic  work,  to 
make  and  mend  the  wearing  apparel,  to  accomplish  ordinary  repairs,  to 
construct  new  buildings,  and  to  fashion  the  furniture. 

8.  The  whole  scheme  requires  to  be  under  medical  supervision, 
and  the  scientific  aspects  of  the  community  thus  created  should  be 
kept  continually  in  mind.  This  necessitates  the  establishment  of 
psychological  and  pathological  laboratories  after  the  most  approved  style. 

As  an  instance  of  what  species  of  work  may  be  done  by  defectives 
in  institutions,  Bourneville's  statistics  of  occupations  at  Bic6tre  for 
1897  show  that  there  were  187  children  employed  in  the  various  shops 
and  workrooms,  among  them  being:  10  brushmakers,  24  carpenters,  9 
printers,  14  locksmiths,  51  tailors,  28  shoemakers,  and  14  straw-  and 
cane-workers.  The  hemiplegics  work  exclusively  at  sewing,  and  the 
blind  with  straw  and  cane.  The  colony  plan,  however,  would  insure  a 
greater  amount  of  healthier  work  out  of  doors  than  is  possible  at  such 
a  place  as  Bicetre,  and  would  be  more  remunerative  to  the  administration. 

Moral  Training-  and  Discipline. — Much  as  the  inculcation  of 
moral  ideas  is  needed  for  normal  children,  defectives  require  even 
more  attention  in  this  respect ;  for  in  them  the  abrogation  of  higher  in- 
telligence is  associated  naturally  with  feeble  inhibitive  power.  Thus 
they  easily  give  way  to  the  lower  instincts,  and  are  prone  to  acquire 
vicious  habits  of  conduct  and  speech.  In  some  cases  the  moral  obliquity 
is  so  great  that  it  constitutes  the  so-called  moral  imbecility,  and  little  can 
be  accomplished  for  their  improvement.  But  the  majority  of  defectives 
are  susceptible  to  the  influences  of  a  good  environment  and  moral  disci- 
pline. Imitation  of  the  teacher  and  of  playmates  and  schoolmates  counts 
for  much  with  them.  The  judicious  instructor  and  care-taker  can,  by 
firm  and  kindly  guidance,  accomplish  great  good  in  this  respect,  and  it 
should  always  be  kindly  guidance,  never  coercion.  There  is,  however, 
merit  in  the  employment  of  a  system  of  rewards  and  punishments 
adapted  to  the  idiosyncrasies  of  the  different  pupils.  A  few  words  of 
encouragement  or  praise,  or  trifling  compensations  in  the  way  of  extra 
allowances  of  food,  delicacies,  recreations,  or  small  wages,  appeal  dis- 


IDIOCY.  815 

tinctly  to  some  ;  while  words  of  disapproval,  the  curtailing  of  things 
pleasant  to  the  palate,  the  deprivation  of  souk;  anticipated  pleasure,  and 
so  on,  have  especial  influence  with  others,  it  is  a  good  plan  to  dis- 
tinguish the  pupils  for  meritorious  conduct  and  industrial  accomplish- 
ments by  distinctive  dress,  thus  appealing  to  their  ambitions.  It  is  well 
to  establish  three  or  four  grades  to  be  thus  distinctively  recognized,  for 
nothing  is  more  human  than  the  instinct  to  appear  well  to  others,  to  be 
among  the  best-dressed.  The  instinctive  desire  of  the  savage  for  orna- 
ment is  no  stronger  than  that  of  the  most  civilized  being  for  good 
•clothes.  The  mentally  feeble  are  no  strangers  to  this  feeling,  and  their 
good  conduct  can  be  enhanced  and  maintained  by  promotion  to  a  better 
clothed  division,  and  their  shortcomings  well  punished  by  reduction  to  a 
lower  rank.  Corporal  punishment  is  both  necessary  and  useful  in  ex- 
treme cases  with  vicious  tendencies,  but  should  be  a  last  resort  even  here. 

By  the  means  just  described,  and  by  other  devices  that  will  sug- 
gest themselves  to  the  wise  and  tactful  person  whom  we  suppose  to  be 
intrusted  with  their  care,  these  unfortunates  may  be  taught  obedience, 
perseverance,  responsibility,  and  regard  for  the  rights  of  others,  and  be  im- 
bued with  some  knowledge  of  the  great  laws  of  justice,  beauty,  goodness, 
and  religion  which  rule  the  ideal  world  of  humankind. 

Physical  Culture. — The  tendency  to  incorrectness  of  gesture  and 
bearing,  the  great  lack  of  strength  and  grace,  among  idiots,  must  be 
•overcome  by  systematic  education  of  the  muscles.  There  should  be 
courses  of  gymnastic  exercises  and  drills,  with  song  and  instrumental 
accompaniments.  The  drills  may  be  made  with  wands,  light  dumb- 
bells, etc.  Military  drill  is  excellent  for  both  girls  and  boys.  Dancing 
is  beneficial  to  both  mind  and  body.  Bourneville  has  introduced 
fencing  at  Bicetre,  but  does  not  speak  of  it  with  enthusiasm. 

The  Medical  Treatment  of  Idiots. — The  medical  and  surgical 
treatment  of  the  different  forms  of  idiocy  is  thoroughly  discussed  under 
their  several  chapters  in  this  book,  and  it  is  intended  here  to  refer  only 
to  the  treatment  of  certain  general  conditions  met  with  in  all  classes  and 
grades  of  idiocy.  Among  such  conditions  are  some  that  relate  to  hy- 
giene, and  others  that  pertain  to  bad  habits,  general  diseases,  and  the  like. 

Hydrotherapy. — The  rain-bath  is  nowadays  considered  a  necessary 
adjunct  to  all  public  institutions,  because  of  expedition  in  its  use  and 
perfect  cleanliness.  Such  baths  should  be  the  daily  morning  rule  of 
defectives.  The  skin  is  kept  in  a  hygienic  state,  the  circulation  is 
stimulated,  and  general  nutrition  is  improved  by  the  morning  bath.  In 
lethargic  or  apathetic  states  the  cold  spinal  douche  is  beneficial,  while 
in  very  restless  patients  the  prolonged  warm  bath  and  wet-packs  at 
night  often  materially  aid  in  overcoming  the  condition. 

Clothing-. — One  of  the  noteworthy  stigmata  of  degeneration  common 
to  all  classes  of  idiocy  is  a  diminished  resistance  to  external  influences 
and  diseases.  They  catch  cold  easily.  Tuberculosis  and  other  lung  dis- 
orders account  for  nearly  seventy-five  per  cent,  of  the  mortality  among 
them.  Diarrheas  are  common.  Hence  it  is  important  that,  among 
other  things,  considerable  attention  should  be  given  to  clothing.  Woolen 
undergarments  of  warm  and  light  texture  should  be  the  rule.     The 


816  MENTAL   DISEASES. 

outer  clothing  should  be  light,  durable,  neat,  of  prevailing  cuts  and 
styles,  and  none  of  the  clothing  should  in  any  way  impede  or  restrict 
the  free  motions  of  the  limbs  and  trunk. 

Food. — The  dietary  for  this  class  of  defectives  should,  in  my 
opinion,  closely  approximate  that  of  epileptics — i.  e.,  it  should  be  chiefly 
vegetable,  with  the  free  use  of  milk  and  eggs,  and  meat  but  once  daily. 
Simplicity  of  food  and  simple  cooking  are  essential.  The  dietary  need 
not  be  so  elaborate  as,  for  instance,  in  hospitals  or  asylums,  where  acute 
disorders  are  commonly  treated,  and  where  the  percentage  of  cure  is 
expected  to  be  large.  Idiots  are  apt  to  overeat,  and  hence  the  chief 
requisite  is  to  regulate  the  per  capita  allowance  to  just  the  amount 
necessary  to  maintain  a  robust  state  of  physical  health.  Overeating  is 
probably  responsible  for  much  of  the  diarrhea  commonly  observed 
among  these  cases. 

General  Bodily  Health. — Very  common  is  a  condition  of  general 
debility,  which  must  be  met  by  appropriate  tonics,  nutritive  foods, 
special  baths,  massage,  and  regular  exercise.  The  great  mortality  from 
tuberculosis  should  lead  the  physician  to  a  regular  examination  of  the 
viscera  for  symptoms  of  that  disorder.  When  discovered,  the  usual 
precautions  should  be  taken  to  isolate  the  patient  and  to  build  up  the 
constitution  in  every  way.  Parasitic  and  nervous  skin  diseases  will 
often  need  attention.  The  prevailing  mucous  diarrheas  are  treated  by 
the  usual  remedies  and  by  careful  regulation  of  the  kind  and  amount  of 
food.  Owing  to  feebleness  of  constitution  and  diminished  resistance  to 
diseases,  especial  danger  attaches  to  acute  infectious  fevers  in  idiots. 

Masturbation. — The  prevalence  of  this  pernicious  habit  among  all 
classes  of  idiots  is  only  too  pronounced.  In  the  lowest  grades  it  is  un- 
common, but  among  the  imbeciles  and  feeble-minded  it  is  one  of  the 
most  intractable  of  conditions.  There  are  few  agents  and  devices 
which  have  not  been  tried,  and  usually  vainly,  to  prevent  the  practice. 
It  is  only  rarely  that  vesication  of  the  genitals,  punishment,  mechanical 
restraint  of  the  limbs,  and  sedative  drugs  have  any  effect  in  the  treat- 
ment of  defectives.  Indeed,  they  might  usually  as  well  be  left  untried. 
There  have  been  very  few  experiments  of  the  method  of  cure  by  cas- 
tration, for,  naturally,  professional  opinion  is  too  conservative  to  under- 
take, without  long  and  careful  deliberation,  so  radical  a  remedy.  I  know 
of  but  one  institution  where  castration  has  been  apparently  adopted  as 
a  part  of  the  regular  system  of  care  and  treatment.  The  superintendent 
of  the  Winfield,  Kansas,  Asylum  for  Idiots  has  had  between  twenty 
and  thirty  boys  who  were  inveterate  masturbators  subjected  to  castra- 
tion, with  excellent  results.  Not  only  were  their  vicious  habits  put  an 
end  to,  but  there  was  marked  physical  improvement  in  all,  and  great 
mental  improvement  in  most,  of  them.  There  would  seem  to  be  no 
reasonable  objection  to  operative  procedure  in  such  cases,  though,  per- 
haps, it  is  hardly  necessary  to  go  so  far  as  castration.  Ligature  of  the 
vas  deferens,  or  possibly  section  of  some  branch  of  the  pudic  nerve, 
might  serve  as  well.  At  any  rate,  some  method  of  this  kind  is  well 
worthy  of  consideration,  though  the  ultimate  decision  of  the  profession 
as  to  its  utility  and  propriety  has  yet  to  be  learned. 


INDEX. 


Abdominal  reflex,  34 
Abscess  of  brain,  229 
diagnosis  of,  232 
encysted,  230 
etiology  of,  229 
invasion  stage  of,  231 
latent  period  of,  231 
multiple,  230 
paralytic  stage  of,  231 
pathological  anatomy  of,  229 
prognosis  of,  233 
remission  stage  of,  231 
symptoms  of,  231 
treatment  of,  233 
Accessory,  spinal,  140.     See  Spinal  acces- 
sory nerve 
Accommodation,  errors  of,  importance  of, 
61 
in  multiple  neuritis,  305 
Acetanilid  in  tabes  dorsalis,  420 
Acetouuria  in  insanity,  675 
Achilles  tendon-reflex,  36 
Achromatopsia,  63 
Aconite  in  cerebral  hemorrhage,  208 

in  hematomyelia,  333 
Aconitia  of  Duquesnel  in  neuralgia,  590 
Acrocephalus,  617 
Acromegalia,  457 
course  of,  462 
diagnosis  of,  462 
differential  diagnosis  of,  462 
etiology  of,  457 
forms  of,  462 
morbid  anatomy  of,  458 
prognosis  of,  462 
symptoms  of,  459 
treatment  of,  462 
Acroparesthesia,  598 
Actinomycosis  of  brain,  236 
Actions,  disorders  of,  669 
induced  by  defects  of  memory,  669 
by  disorders  of  emotions,  669 

of  idea-association,  670 
by  sensory  disorders,  669 
Active  electrode,  42 
Acupuncture  in  sciatic  neuritis,  295 
Acute  anterior  poliomyelitis,    356.     See 
Poliomyelitis 
ascending  paralysis,  344.     See  Landry's 

paralysis 
dementia,  728 

52  817 


Acute  infectious  diseases  in  etiology  of  in- 
sanity, 638 
Addison's  keloid,  482 
Adonis  vernalis  in  epilepsy,  723 
Adventitious  neuritis,  271 
Affective  agitation,  670 
Age  in  etiology  of  insanity,  610 
Ageusia,  64 

Agitated  dementia,  725 
Agoraphobia,  667 
Agraphia  with  motor  aphasia,  169 
Alcohol  in  cerebral  hemorrhage,  208 

in  etiology  of  insanity,  635 
Alcoholic  neuritis,  308 

prognosis  of,  313 
Alexia,  77 

Alienation  mentale,  603 
Alimentary  canal,  examination  of,  24 
Allocheiria,  50 
Alternating  insanity,  711 
Amaurotic  family  idiocy,  252 
Amenorrhea  in  insanity,  675 
American  disease,  528 
Amimia,  67,  167 
Amnesia  verbalis,  67 
Amputation  neuroma,  276 
Amusia,  167 

Amyelinic  neuromata,  276 
Amyl  nitrite  in  angina  pectoris,  139 

in  Raynaud's  disease,  485 
Amyleue  hydrate  in  mental  disease,  690 
Amyotrophic  lateral  sclerosis,   371.     See 

Progressive  muscular  atrophy,  spinal 
Anal  reflex,  36 
Analgesia,  50 

in  myelitis,  336 

in  syringomyelia,  367 

in  tabes  dorsalis,  400 
Anemia,  cerebral,  187 

pernicious,  lesions  of  spinal  cord  from, 
350 
Anesthesia,  50 

from   lesion  of  anterior  crural  nerve, 
288 

from  lesion  of  circumflex  nerve,  280 

from  lesion  of  external  plantar  nerve, 
290 

from  lesions  of  spinal  cord,  325 

from  paralysis  of  sciatic  nerve,  289 

hysterical,  55,  540 
distribution  of,  543 


818 


INDEX. 


Anesthesia,  hysterical  peculiarities  of,  544 

in  mental  disease.  654 

in  syringomyelia,  367 

of  larynx,  133 

relation  of,  to  lesions  of  cord,  31 

relation  of,  to  lesions  of  nerve-trunks, 
51 
Aneurysms  of  brain,  236 
Anger,  659 
Angina  pectoris,  138 

hysterical,  559 
Angioma  of  brain,  236 
Angioneurotic  edema,  486 
diagnosis  of,  487 
etiology  of,  486 
prognosis  of,  487 
symptoms  of,  486 
treatment  of,  487 
Anhedonia,  655 
Ankle-clonus,  36 

spurious,  36 
Anodal  closing  contraction,  43 

opening  contraction,  43 
Anodynes  in  neuritis,  275 

in  neuromata,  278 
Anomalies,  dental,  in  insanity,  626 

of  appetite  in  insanity,  634 

of  body  in  insanity,  632 

of  cranium  in  insanity,  614 

of  ear  in  insanity,  627 

of  eyes  in  insanity,  627 

of  genital  organs  in  insanity,  632 

of  genito-urinary  function  in  insanity, 
634 

of  instinct  in  insanity,  634 

of  limbs  in  insanity,  632 

of  lips  in  insanity,  626 

of  motor  function  in  insanity,  633 

of  nose  in  insanity,  627 

of  sensory  function  in  insanity,  633 

of  skin  in  insanity,  633 

of  speech  in  insanity,  634 

of  tongue  in  insanity,  626 
Anorexia,  hysterical,  560 
Anterior  horn  of  cord,  effect  of  lesions  of, 
327 

median  artery  of  cord,  318 

roots  of  cord,  effect  of  lesions  of,  328 

spinal  artery,  318 
Antipyretics  in  tubercular  leptomeningi- 
tis, 93 
Antipyrin,  576 

in  brain-tumor,  244 

in  chorea,  509 
Antiseptics  in  sinus  thrombosis,  226 
Anxiety,  658 
Apathetic  dementia,  725 
Apathy,  659 
Ape  hand,  283,  374 
Aphasia,  66,  165 

auditory,  168 

combined,  173 

conduction,  171 

examination  and  testing  of,  66 

graphic-motor,  171 

in  cerebral  hemorrhage,  200 

in  tumor  of  brain,  240 


Aphasia,  motor,  168 

handwriting  in,  169 
varieties  of,  165 
visual,  170 
Aphasics,  reeducation  of,  173 
Aphemia,  168 
Aphonia  in  hysteria,  66 
Aphthougia,  144 
Apoplectic  state,  198 

"stroke,"  198 
Apoplexy,  ingravescent,  205 
Appetite,  anomalies  of,  634 
Arachnopia,  70 
Arc  de  cercle,  552 
Argyll- Robertson  pupil,  32 

in  insanity,  673 
Arm,  nerves  of,  combined  palsies  of,  285 
Arsenic  in  chorea,  509 
in  multiple  neuritis,  314 
in  neurasthenia,  538 
Arterial  brain  diseases,  185 
Arteries,  acute  degeneration  of,  195 
of  brain,  185 
of  spinal  cord,  318 
Arteriosclerosis,  cerebral,  191 
symptoms  of,  192,  193 
treatment  of,  193 
Arteritis,  cerebral,  190 
syphilitic  cerebral,  444 
of  brain,  194 
symptoms  of,  447 
Artery,  anterior  median,  of  cord,  318 

spinal,  318 
Arthritic  muscular  atrophy,  38,  387 
diagnosis  of,  389 
etiology  of,  387 
morbid  anatomy  of,  388 
pathology  of,  388 
prognosis  of,  389 
symptoms  of,  387 
treatment  of,  389 
Arthritis,  relation  of,  to  chorea,  500 
Arthropathies  in  syringomyelia,  368 
Arthropathy,  dystrophic,  38 

tabetic,  410 
Aschistodactyly,  632 
Associated  movements,  30 

in  infantile  cerebral  palsies,  249 
Astasia  abasia,  557 
Asthenic  bulbar  paralysis,  153 
Asthma,  bronchial,  134 
symptoms  of,  135 
treatment  of,  135 
spasmodic,  134.     See  Asthma,  bronchial 
Asylums  for  insane,  681 
Asymmetrical  palate,  622,  625 
Asymmetry,  facial,  620 
of  skull,  616 

physiological,  616 
Atavism  in  mental  and  nervous  diseases,  18 
Ataxia,  detection  of,  28,  29 

family,  425.     See  Family  ataxia 
Friedreich's,  425.     See  Family  ataxia 
hereditary  cerebellar,  425 
in  tabes  dorsalis,  397 
locomotor,  progressive,  390.     See  Tabes 
dorsalis 


INDEX. 


8  I  9 


Ataxia,  progressive  spastic,  421 

static,  29 
Ataxic  gait,  397 

handwriting,  29 

paraplegia,  421 
syphilitic,  451 
Atheroma  of  cerebral  vessels,  190 
Atheromatous  arteries  in  etiology  of  in- 
sanity, 639 
Athetoid  movements  in  infantile  cerehral 

palsies,  248 
Athetosis,  30 

in  infantile  cerebral  palsies,  248 

treatment  of,  254 
Atrophia  muscularis  progressiva  spinalis, 

371 
Atrophy,  arthritic  muscular,  38,  387 

from  lesions  of  spinal  cord,  326 

in  facial  paralysis,  119 

in  multiple  neuritis,  301 

in  myelitis,  337 

in  syringomyelia,  368 

of  optic  nerve,  101 

progressive   muscular,    370.      See  Pro- 
gressive muscular  atrophy 
A  tropin  in  etiology  of  insanity,  637 

in  myoclonia,  513 
Attention,  disorders  of,  662 
Attitude,  importance  of,  27 

in  idiopathic  muscular  atrophy,  383 

in  paraplegia,  343 

in  sciatic  neuritis,  292 
Auditory  aphasia,  168 

hyperesthesia,  63,  124,  125 

nerve,  irritation  of,  124 
paralysis  of,  125 

symptoms  in  cerebellar  disease,  179 
Aurse,  epileptic,  568 
Aural  vertigo,  126 
diagnosis  of,  127 
treatment  of,  128 
Auriculobregmatic  radii,  617,  620 
Autohypnosis,  599 
Auto-intoxication  in  etiology  of  insanity, 

635 
Aztec  ear,  629 


Bacillus  coli  in  leptomeningitis,  77 
tubercle  in  tubercular  meningitis,  89 

Basal  ganglia,  functions  and  lesions  of,  176 

Basedow's  disease,  472.    See  Exophthalmic 
goiter 

Basilar  meningitis,  88.    See  Leptomeningi- 
tis, tubercular 

Basion,  618 

Batteries  for  electrical  testing,  39,  40 

Beard's  disease,  528 

Bedsore  in  cerehral  hemorrhage,  200 

Belladonna  in  epilepsy,  576 
in  exophthalmic  goiter,  481 
in  nocturnal  enuresis,  597 

Bell's  palsy,  116 

Benedikt's  calipers,  618,  619 

Beri-beri,  296,  310 

Betanaphtol,  576 
in  auto-intoxication,  688 


Betanaphtol  in  epilepsy,  723 

in  myelitis,  ■';  10 
Bichlorid  of  mercury  in  anterior  myelitis, 

363 
in  Landry's  paralysis,  347 
Binauricnlar  arc.  017,  620 

diameter,  617,  620 
Blainville  ear,  62fi 
Blepharospasm  as  a  symptom,  60 
Blindness,  functional,  101 

toxic   101 
Body,  anomalies  of,  632 
Brachial  plexus,  lesions  of,  285 

neuritis  of,  286.     See  Neuritis 
Brachycephalic  head,  615 
Bradycardia.  137 
Brain,  abscess  of,  229.    See  Abscess  of  brain 

aneurysms  of,  236 

arterial  supply  of,  185 

carcinoma  of,  235 

cysts  of,  236 

disease,  pain  in,  60 

glioma  of,  234 

gliosarcoma  of,  235 

inflammation  of,  226 

lesions  of,  destructive,  180 
general  considerations  of,  180 
irritative,  180 

sarcoma  of,  234 

softening  of,  210 

syphilis  of,  444.     See  Syphilis,  cerebral 

tubercle  of,  234 

tumors  of,  233.     See  Tumors  of  brain 
syphilitic,  236 
Brandy  in  mania,  700 
Break  of  current,  42 
Bregmatolambdoid  arc,  62,  617 
Bright's  disease  as  predisposing  to  ner- 
vous disease,  19 
Brodie's  joints,  546 
Bromid  in  cerebral  softening,  218 

of  potassium  in  tubercular  leptomenin- 
gitis of  children,  93 
Bromids  in  brain-tumor,  244 

in  epilepsy,  576,  722 

of  infantile  cerebral  palsy,  254 

in  exophthalmic  goiter,  481 

in  mental  disease,  690 

in  multiple  neuritis,  315 

in  paralytic  dementia,  742 

in  senile  dementia,  728 

in  tetanus,  492 
Bronchial  asthma,  134.     See  Asthma 
Brown-Sequard  paralysis,  cord  lesion  in, 

51,  55 
Bruit  in  intracranial  aneurysms,  184 
Bulbar  paralysis,  acute,  154 
astbenic,  153 

regressive,  148.     See  Polio- encephal- 
itis inferior  chronica 
Bulbocavernous  reflex,  407 
Bulimia,  655 


Cachexia  strumipriva,  465 
Caffein  in  brain-tumor,  245 
in  migraine,  581 


820 


INDEX. 


Cagot  ear,  630 
Caisson  disease,  347 
etiology  of,  348 
morbid  anatomy  of,  348 
prophylaxis  of,  349 
symptoms  of,  349 
treatment  of,  349 
Calabar  bean  in  tetanus,  492 
Calipers,  618,  619 
Calomel  in  hydrocephalus,  258 
in  leptomeniugitis,  84 
in  tubercular  leptomeningitis,  93 
Camphor  in  bronchial  asthma,  136 
Cannabis  indica  in  etiology   of  insanity, 
637 
in  Parkinson's  disease,  519 
in  torticollis,  141 
Carcinoma  in  etiology  of  insanity,  639 

of  brain,  235 
Cardiac   branches   of  vagus,    diseases  of, 
136 
palpitation,  137 
Cardiopathy,  relation  of,  to  chorea,  500 
Cardiothyroid  exophthalmos,  472 
Case-book,  value  of,  68 
Catatonic  melancholia,  705 

rigidity,  703 
Cathodal  closing  contraction,  43 
tetanus,  43 
opening  contraction,  43 
Cauda  equina,  localization  of  lesions  of, 

328 
Center  for  eye-movements,  159 
for  hearing,  161 
for  larynx,  160 
for  lips,  160 

for  lower  extremities,  160 
for  lower  face  movements,  158 
for  mastication,  160 
for  motor  speech,  160 
for  pharynx,  160 
for  smell,  162 
for  speech,  164 
for  taste,  162 
for  toes,  160 

for  tongue  movement,  158 
for  trunkal  movements,  160 
for  upper  extremities,  1 59 

face  movements,  158 
for  vision,  161 
Centers,  cortical,  158 

relation  of  body  to,  160 
for  word  memories,  164 
motor,  of  cerebral  cortex,  158 
Central  canal  of  cord,  effect  of  lesions  of, 
328 
myelitis,  334 
scotoma,  98 
Cephalalgia,  hysterical,  558 
Cephalic  index,  615 

tetanus,  491 
Cerebellar  hemorrhage,  205 
Cerebellospasmodic  gait,  437 
Cerebellum,  function  of,  178 

symptoms  of  lesions  of,  178 
Cerebral  anemia,  187 
diagnosis  of,  188 


Cerebral  anemia,  etiology  of,  187 
symptoms  of,  187 
treatment  of,  188 
arteriosclerosis,  191 
arteritis,  190 

syphilitic,  194 
cortex,  cells  of,  156 
latent  lesions  of,  162 
lesions  of,  effects  of,  on  sensation,  55 
localization  in,  155.    See  Localization, 

cerebral. 
motor  centers  of,  158 
unknown  functions  of,  162 
hemorrhage,  195.     See  Hemorrhage 
hyperemia,  188 
diagnosis  of,  189 
etiology  of,  188 
symptoms  of,  189 
lesions  in  tabes  dorsalis,  396 
meninges,  anatomical  considerations,  70 

diseases  of,  70 
meuingitis,  syphilitic,  444 
palsies  of  children,  245 

causes  attending  birth,  246 
classification  of,  247 
diagnosis  of,  253 
diplegic  cases,  250 
epileptic  attacks  in,  253 
etiology  of,  245 
hemiplegic  cases,  248 
morbid  anatomy  of,  247 
postnatal  causes  of,  246 
prenatal  causes  of,  245 
prognosis  of,  253 
symptoms  of,  247 
treatment  of,  254 
periarteritis,  190 
sinuses,  219 
softening,  210 

abrupt  onset  in,  213 
course  of,  215 
diagnosis  of,  215 
differential  diagnosis  of,  216 
etiology  of,  212 
location  of,  212 
paralytic  state  in,  214 
pathological  anatomy  of,  210 
prognosis  of,  217 
progressive  onset  in,  214 
red,  211 

sensory  disturbances  in,  215 
symptoms  of,  213 
treatment  of,  218 
white,  211 
yellow,  211 
syphilis.  444.     See  Syphilis,  cerebral 
veins,  219 

white  matter,  function  of,  in  localiza- 
tion, 174 
Cerebritis,  226 

acute  localized,  226,  228 
etiology  of,  226 
pathological  anatomy  of,  227 
symptoms  of,  227 
treatment  of,  228 
chronic,  229 
from  cerebral  hemorrhage,  200 


INDEX. 


821 


Cerebritis,  syphilitic,  444 
( lerebroma,  \l'.W 

Cerebrospinal  meningitis,  76.     See  Lepto- 
meningitis 
Charcot-Marie  disease,  386 
Charcot's  disease,  371,  377 

joints,  38,  411 
Chemocephalus,  616 
Chiasm,  optic,  lesion  of,  96,  99 
Children,   cerebral  palsies  of,   245.      See 

Cerebral  palsies  of  children 
Chirospasm,  522 
Chloral  hydrate  in  mental  disease,  690 

in  chorea,  509 

in  insomnia,  594 

in  multiple  neuritis,  315 

in  paralytic  dementia,  742 

in  status  epilepticus,  723 

in  tetanus,  492 
Chlorid  of  iron  in  anterior  poliomyelitis, 
363 
tincture  of,  in  Landry's  paralysis,  347 
Chloroform  in  angina  pectoris,  139 

in  bronchial  asthma,  136 

in  tetanus,  492 
Cholesteatoma  of  brain,  236 
Chorea,  499 

adult  hereditary,  510 

cardiac  disorders  in,  505 

chronic,  510 

complications  of,  509 

corpuscles,  502 

course  of,  506 

diagnosis  of,  508 

electric,  513 

etiology  of,  499 

family,  510 

fibrillary,  512 

forms  of,  507 

general  state  in,  506 

gravidarum,  507 

gravis,  507 

Huntingdon's,  510 

limp,  508 

mental  symptoms  of,  505 

minor,  499 

morbid  anatomy  of,  502 

motor  symptoms  of,  503 

of  pregnancy,  507 

of  Sydenham,  499 

of  the  aged,  510 

paralytic,  508 

pathogenesis  of,  501 

prognosis  of,  508 

relations  of  rheumatism  to,  500 

senile,  512 

symptoms  of,  502 

treatment  of,  508 
Choreoid  movements  in  infantile  cerebral 

palsies,  248 
Choroiditis  in  leptomeningitis,  80 
Chronic  delusional    insanity,    743.      See 

Paranoia 
Chvostek's  sign,  497 
Ciliary  reflex,  32 
Circular  insanity,  711 
course  of,  715 


Circular  insanity,  definition  of.  609,  711 

diagnosis  of,  71". 
etiology  of,  71 1 
maniacal  period  of,  71  ■> 
melancholic  period  of,  711 
pathological  anatomy  of,  714 
prognosis  of,  716 
symptomatology  of,  711 
treatmenl  of,  7 if; 
varieties  of,  714 
Circulatory  apparatus,  examination  of,  24 
Circumflex  nerve,  lesions  of,  279 
(  I.Mistrophobia,  667 
Cleft-palate,  623 
Clonic  convulsions,  31 

spasm,  30 
Clonus,  ankle-,  36 
foot-,  36 
rectus,  35 
wrist,  34 
Cocain  in  etiology  of  insanity,  637 
in  multiple  neuritis,  315 
in  myoclonia,  513 
in  neuralgia,  590 
in  sciatic  neuritis,  295 
Codein  in  epilepsy,  723 

in  mental  disease,  689 
Color-blindness,  63 
Combined  aphasias,  173 
palsies  of  nerves  of  arm,  285 
sclerosis  of  the  spinal  cord,  421 
course  of,  423 
diagnosis  of,  424 
etiology  of,  421 
morbid  anatomy  of,  422 
prognosis  of,  424 
symptoms  of,  422 
treatment  of,  424 
tabes,  421 
Commotion  insanity,  640 
Concussion  of  spine,  581 
Conduction  aphasias,  171 
Congenital  myxedema,  467 

paramyotonia,  520 
Conjunctivitis  in  facial  paralysis,  119 
Consanguinity  of  parents  as  a  predispos- 
ing cause  of  nervous  disease,  18 
Consonant  production,  table  of,  65 
Constant  current,  test  of,  in  health,  43 
Contraction,  anodal  closing,  43 
opening,  43 
cathodal  closing,  43 

opening,  43 
front-tap,  36 
paradoxical,  36 
Contracture,  30 

Contractures  from  cord-lesions,  323 
in  infantile  cerebral  palsies,  248,  250 
in  multiple  neuritis,  302 
of  hysteria,  555 
Convulsions,  30 
clonic,  31 
general,  30 

in  cerebral  palsies  of  children,  248 
in  leptomeningitis,  79 
in  tubercular  leptomeningitis,  91 
in  tumor  of  brain,  238 


822 


INDEX. 


Convulsions,  Jacksonian,  30 

local,  30 

tonic,  31 
Coprolalia,  583,  668 

Cord-lesions,   horizontal    localization    of, 
327 

indiscriminate,  330 

motor  symptoms  of,  323 

paralysis  from,  323 

reflexes  in ,  325 

sensory  symptoms  of,  325 

trophic  conditions  in,  326 

vasomotor  disturbance  in,  326 

visceral  symptoms  of,  326 
Cord-substance,  traumatic  lesions  of,  330 
Corona  radiata,  function  of,  174 
Corpora  quadrigemina,  function  of,  177 
lesions  of,  99 
symptoms  of  lesion  of,  177 

striata,  function  of,  176 
Corpus  callosum,  function  of,  174,  175 
Cortex,  cerebral.     See  Cerebral  cortex 
Cortical  localization,  motor,  158 
sensory,  160 

paralysis  in  insanity,  672 
Coughs,  nervous,  134 

Counterirritation  in  combined  sclerosis  of 
cord,  424 

in  Landry's  paralysis,  347 

in  neuritis,  275 

in  sciatic  neuritis,  294 

in  spinal  leptomeningitis,  265 

in  syringomyelia,  370 

in  tabes  dorsalis,  418 
Coxalgia,  hysterical,  557 
Cramp,  30 

writers',  522 
Crania  progenaea,  618 
Cranial  anomalies,  6 1 4 

nerves,  affections  of,  in  leptomeningitis, 
80 
lesions  of,  in  tabes  dorsalis,  395 
multiple  paralyses  of,  145 
syphilitic  lesions  of,  445 
Craniocerebral  topography,  162 
Craniometrical  measurements,  617 

table  of,  620 
Cranium,  anomalies  of,  614 

deformities  of,  614 

measurement  of,  617 

physiological  asymmetry  of,  615 
Cranks,  743 
Cremasteric  reflex,  36 
Cretinism,  471 

sporadic,  467 
Crises,  gastric,  405 

nephritic,  407 

tabetic,  405 

visceral,  405 
Crura  cerebri,  function  of,  177 

results  of  lesions  of,  177 
Crural  nerve,  anterior,  lesions  of,  288 
Curare  in  tetanus,  492 
Current,  break  of,  42 

make  of,  42 
Cutaneous  areas,   relation   of,   to  spinal- 
cord  segments,  54,  57 


Cutaneous    distribution    of    nerves,    52,. 
53 
sensibility,  electrical  testing  of,  47 
Cyclic  psychosis,  711 
Cycloplegia,  61 
Cysts  of  brain,  236 


Daltonism,  63 
Darwin  ear,  629 

Deafness,  diagnosis  of  cause  of,  126 
lesion  causing,  161 
nervous,  125 

treatment  of,  126 
word-,  125 
Debilitating  diseases   as   predisposing  to 

nervous  disease,  18 
Decubitus  from  trophic  disturbance,  39 
Deformity  from   cerebral  palsies  of  chil- 
dren, 248 
Degeneracy,  stigmata  of,  21 
Degeneration,  reaction  of,  45 

secondary,  of  divided  nerve,  269 
stigmata  of,  612 
Delire  de  negation  generalize,  666 
Delirium,  inanition,  638 

in  anterior  poliomyelitis,  359 
in  leptomeningitis,  79 
in  multiple  neuritis,  306 
Delusion  of  grandeur,  666 
of  negation,  666 
of  persecution,  665 
Delusions,  664 

effect  of,  on  actions,  671 
in  paralytic  dementia,  737 
systematization  of,  667 
Dementia,  609,  724 
acute,  728 
agitated,  725 
apathetic,  725 
definition  of,  724 
epileptic,  718 
from  mania,  698 
paralytic,  724,  730 
definition  of,  730 
diagnosis  of,  739 
duration  and  prognosis  of,  738 
etiology  of,  730 
pathological  anatomy  of,  741 
symptomatology  of,  732 
treatment  of,  742 
paralytica,  609 
primary,  609,  724,  728 

course  and  prognosis  of,  729 
definition  of,  728 
etiology  of,  728 
pathological  anatomy  of,  729 
symptomatology  of,  728 
treatment  of,  729 
secondary,  609,  724,  725 

course  and  prognosis  of,  726 
pathological  anatomy  of,  726 
symptomatology  of,  725 
senile,  724,  726 

course  and  prognosis  of,  727 
diagnosis  of,  727 


INDEX. 


823 


Dementia,  senile,  etiology  of,  726 
pathological  anatomy  of,  728 
symptomatology  of,  726 
treatment  of,  728 

terminal,  609 
Depression,  657 

Dermographism  in  hysteria,  561 
Destructive  brain-lesions,  180 
Destruetiveness   in  insane,    management 

of,  69:3 
Diabetes  a  predisposing  cause  to  nervous 

disease,  19 
Diagnosis  in   neurology,  importance  and 

difficulty  of,  17 
Diet  in  insanity,  686 

in  leptomeningitis,  86 
Diffused  symptoms,  182 
Digitalis  in  epilepsy,  576,  723 

in  exophthalmic  goiter,  481 
Digiti  mortui,  484 

Digits,  center  for  movements  of,  160 
Diphtheric  paralysis,  309 
Diplegia,  28 

in  infantile  cerebral  palsies,  250 
Diplococcns  intercellularis   meningitis  in 

leptomeningitis,  77 
Diplopia,  61 

in  ocular  paralysis,  105 

monocular,  61 

test,  106 
Disease,  electrical  tests  in,  44 
Diseases  in  etiology  of  insanity,  638 
Disorders  of  actions,  669 

of  idea-associations,  660 
Disseminated  myelitis,  334 

sclerosis,    434.      See   Multiple    cerebro- 
spinal sclerosis 
Disuse  as  a  cause  of  trophic  disturbance, 

39 
Divers'  palsy  or  paralysis,  347 
etiology  of,  348 
morbid  anatomy  of,  348 
symptoms  of,  349 
treatment  of,  349 
Division  of  nerves,  269 
Dolichocephalic  heads,  615 
Dome-shaped  palate,  622,  624 
Dreams,  595 

Drop-foot  in  multiple  neuritis,  299,  300 
Dropped  wrist  iu  multiple  neuritis,  301 

in  musculospiral  disease,  281 
Dubini's  disease,  513 
Duboisin  in  epilepsy,  723 

in  mania,  700 

in  mental  disease,  689 
Duchenne-Aran's  disease,  371,  377 
Dura  mater,  70 

hematoma  of,  72 

inflammation  of,  72.     See  also  Pachy- 
meningitis 
Dynamometer,  hand-,  of  Mathieu,  27 
Dysacousma,  63 
Dysesthesia,  51 
Dyspepsia,  nervous,  140 
Dystrophic  arthropathy,  38 


EAE,  anomalies  of,  627 
Aztec,  629 
Blainville,  628 
Cagot,  630 
Darwin,  c>:!'.> 
insane,  573 
Morel,  <;2h.  629 
Stub  I.  No.  1,  628,  629 
Stalil.    N<».  2,  (i:i!t 
Wihiermuth,  629,  631 
Echolalia,  <i(;,  166 
Ecstacy,  hysterical,  554 
Ectrodactyly,  632 
Ectromelus,  632 
Edema,  acute  circumscribed,  486 

angioneurotic,  486 
Education  of  idiots,  801 
Eighth  cranial  nerve,  anatomical  consid- 
erations of,  123 
diseases  of,  123 
nerve,  auditory  branch  of.      See  Audi- 
tory nerve 
vestibular  branch  of.     See  Vestibular 
nerve 
Elbow,  center  for  movements  of,  160 
Elbow-jerk,  33 
Electric  chorea,  513 
Electrical  conditions,  39 
examination   in    polio-encephalitis    in- 
ferior chronica,  152 
testing,  arrangement  of  electrodes  in,  41 
batteries  for,  39,  4<> 
for  motor  areas  of  brain,  47 
in  disease,  44 

of  cutaneous  sensibility,  47 
of  hearing,  47 
of  taste,  47 
of  vision,  47 
tests  in  health,  42 
Electricity  in  anterior  poliomyelitis,  363 
in  exophthalmic  goiter,  481 
in  facial  paralysis,  122 
in  family  ataxia,  431 
in  infantile  cerebral  palsies,  254 
in  Landry's  paralysis,  347 
in  laryngeal  paralysis,  133 
in  multiple  neuritis,  315 
in  myelitis,  340 
in  neurasthenia,  537 
in  neuritis,  275 

of  brachial  plexus,  288 
in  Raynaud's  disease,  186 
in  sciatic  neuritis,  295 
in  spinal  progressive  muscular  atrophy, 
378 
Electrode,  active,  42 

indifferent,  41 
Electrodes,   arrangement  of,  in  electrical 

testing,  41 
Electrotherapy  in  insanity,  689 
Emotions,  657 

disorders  of,  actions  induced  by,  669 
Empirical  greatest  height  of  head,  617, 

618 
Emprosthotonos  in  cerebellar  disease,  179 
Encephalitis,  acute  hemorrhagic,  228 
diagnosis  of,  229 


824 


INDEX. 


Encephalitis,  acute  hemorrhagic,  etiology 
of,  228 
morbid  anatomy  of,  228 
symptoms  of,  228 
treatment  of,  229 
chronic,  229 

in  cerebral  softening,  211 
Encephalomalacia.    See  Cerebral  softening 
Endarteritis  deformans  of  cerebral  vessels, 

190 
Knfants  ariearre,  469 
Enuresis,  nocturnal,  596 
Epigastric  reflex,  34 
Epilepsia  processiva,  572 
Epilepsy,  565 

attack  of,  568.     See  Ejjileptic  attack 
aurse  of  attacks  of,  568 
complete  convulsion  of,  569 
diagnosis  of,  573 

differential,  574 
ecstacy  in,  554 
etiology  of,  566 
general  state  in,  573 
inciting  causes  of,  566 
in  etiology  of  insanity,  639 
nocturnal,  571 
pathology  of,  567 

postparoxysmal  phenomena  of,  573 
prodromes  of  attacks  of,  568 
prognosis  of,  575 
status  epilepticus  in,  571 
treatment  of,  575 
Epileptic  attack,  568 
aurse  of,  568 
cerebral,  569 
motor,  568 
psychic,  569 
sensory,  569 
clonic  period  of,  570 
complete,  569 
incomplete,  571 

in  infantile  cerebral  palsies,  253 
period  of  stertor,  570 
psychic  equivalents  of,  572 
tonic  stage  of,  570 
dementia,  718 
insanity,  716 

acute  transitory,  719 
chronic,  720 
defined,  609 
diet  in,  723 

moral  treatment  of,  721 
treatment  of,  721 
Epileptics,  psychic  degeneration  of,  717 
Erb's  paralysis,  386 
phenomenon,  497 
Ergot  in  acute  spinal  leptomeningitis,  265 
in  caisson  diseases,  349 
in  spinal  meningeal  hemorrhage,  268 
in  tabes  dorsalis,  420 
Ergotism,  432 

Eruption  in  leptomeningitis,  82 
Erythromelalgia,  310 
Eserin  in  myoclonia,  513 
Esophagismus,  130 
Esthesiometer,  49 
Exalgin  in  chorea,  509 


Exaltation,  658 

Examination  of  patients  in  insanity,  676 

in  nervous  disease,  17 
Exophthalmic  goiter,  472 

cardiovascular  symptoms  of,  475 

course  and  progress  of,  480 

diagnosis  of,  481 

digestive  disturbances  in,  479 

etiology  of,  472 

genital  disturbances  in,  479 

goiter  in,  475 

mental  disturbances  in,  478 

morbid  anatomy  of,  474 

motor  symptoms  of,  477 

ocular  symptoms  of,  476 

respiratory  changes  in,  479 

secretory  symptoms  of,  478 

skin  in,  479 

symptoms  of,  474 
table  of,  480 

treatment  of,  481 

vasomotor  symptoms  of,  478 
Exothyropexy,  482 
Extension  symptoms,  181 
Extrapial  hemorrhage,  74 
Eyes,  anomalies  of,  627 
Eye-strain,  influence  of,  61 


Face,  center  for  movements  of,  158 
Facial  asymmetry,  620 

hemiatrophy  from   disease  of  trifacial 

nerve,  112 
length,  617,  620 
nerve,  114 

anatomical  considerations  of,  114 

paralysis  of,  116.    See  Facial  paralysis 

spasmodic  affections  of,  116 
paralysis,  116 

alternating,  123 

course  of,  120 

diagnosis  of,  120 

double,  119 

nuclear,  122 

peripheral,  etiology  of,  116 

prognosis  of,  121 

supranuclear,  123 

symptoms  of,  117 

treatment  of,  122 
spasm,  116 
Facioscapulohumeral    form  of   muscular 

atrophy,  387 
Falling  sickness,  565 
Family  ataxia,  425 

course  of,  430 

diagnosis  of,  431 

etiology  of,  425 

Friedreich's  form  of,  430 

Marie's  form  of,  430 

morbid  anatomy  of,  427 

prognosis  of,  431 

symptoms  of,  428 

treatment  of,  431 

varieties  of,  430 
chorea,  510 
myotonia,  519 


INDEX. 


825 


Faradic  current,  test  with,  iu  health,  42, 

44 
Fatigue  neuroses,  521 
Feeblemindedness,  608 
Fever,  hysterical,  561 
Fibrillar  neuromata,  276 
Fibrillary  chorea,  512 

tremor,  29 
Fibroma  of  brain,  236 
Fibular  joint,  292 

Field  of  vision,  61.     See  Visual  field 
Fifth  nerve.     See  Trifacial  nerve 
First  cranial  nerve.     See  Olfactory  nerve 
Fixed  point,  61 
Flat-headedness,  616 
Flat-roofed  palate,  622,  624 
Flavor,  64 

Flexibilitas  cerea,  663,  670 
Fly-blister  in  leptomeningitis,  85 
Folie,  603 

a  deux,  644 

du  doute,  668 

imposee,  644 

simultanee,  644 
Foot,  center  for  movements  of,  160 

-clonus,  36 

-drop  in  multiple  neuritis,  299,  300 
Forced  movements  in  cerebellar  disease, 
180 
in  disease  of  labyrinth,  63 

positions  in  cerebellar  disease,  180 
Forgetfulness  in  multiple  neuritis,  306 
Formes  frustes  in  multiple  sclerosis,  441 
Fourth  nerve,  anatomical  considerations 
of,  103 
effect  of  division  of,  104 
Fowler's  solution,  509 
Friedreich's  ataxia  or  disease,  425.     See 

Family  ataxia 
Frontal  lines,  163 
Front-tap  contraction,  36 
Functional  nervous  diseases,  456 

stigmata  of  degeneracy,  22 
Furor  epilepticus,  659 


Gait,  importance  of,  in  diagnosis,  27 

iu  family  ataxia,  428 

in  idiopathic  muscular  atrophy,  383 

in  multiple  neuritis,  299 
sclerosis,  437 

in  Parkinson's  disease,  516 

in  sciatic  neuritis,  292 

paraplegic,  342 
Galvanic  current,  test  of  muscle  by,  in 

health,  44 
Ganglion  neuroma,  276 
Gastralgia,  139 
Gastric  branches  of  vagus,  diseases  of,  139 

crises,  405 
Gastrodynia,  139 
Gastro-intestinal  disorders  in  etiology  of 

insanity,  639 
General  convulsions,  30 

paralysis  of  the  insane,  609,  730.     See 
Paralytic  dementia 

paresis,  609, 730.  See  Paralytic  dementia 


Geniculate  bodies,  lesion  of,  99 
Genital   disease  in  etiology  of  insanity, 
639 

organs,  anomalies  of,  632 
(H-nito-urinary  function,  anomalies  of.  634 

tract,  examination  of,  25 
Giant  swelling,  486 

urticaria,  486 
Gigantism,  462 

Girdle  sensation  in  tabes  dorsalis,  400 
< i-labellar  point,  163 
<  Hioma  of  brain,  234 

of  spinal  cord,  '■>■'>] 
Gliosarcoma  of  brain,  235 
Globus,  130 

hystericus,  549 
Glossopharyngeal  nerve,  anatomical  con- 
siderations of,  129 
diseases  of,  129 
Gluteal  nerve,  lesions  of,  289 

point,  292 
Glycosuria  in  insanity,  675 
Goiter,  exophthalmic,   472.      See  Exoph- 
thalmic goiter 
Gothic  palate,  622 

Gowers'  rule  in  testing  diplopia,  106 
Grandeur,  delusion  of,  666 
Graphic-motor  aphasia,  171 
Graphospasms,  522 
Graves'  disease,  472.      See  Exophthalmic 

goiter 
Gray  matter  of  cord,  lesions  of,  356 


Habit  spasm,  583 

Habitat,  importance  of,  in  diagnosis,  20 
Habits,  investigation  of,  19 
Hallucinations,  649 

conditions  in  which,  occur,  652 

effect  of,  on  actions,  669 

examination  for.  651 

of  memory,  662 

origin  of,  651 
Hallucinatory  agitation,  670 

confusion,  652 

stupor,  652 
Hammer-toe,  290 

in  family  ataxia,  430 
Hand-dynamometer  of  Mathieu,  27 
Handwriting,  examination  of,  67 
Harelip,  626 

Hashish  in  etiology  of  insanity,  637 
Headache  as  a  cerebral  symptom,  182 

in  cerebral  syphilis,  446 

in  leptomeningitis,  79 

in  tubercular  leptomeningitis,  90 

in  tumor  of  brain,  238 

lead-caj),  531 

occipital,  in  cerebellar  disease,  180 
Head  injuries,  in  etiology  of  insanity,  640 

retraction  of,  in  cerebellar  disease,  180 

tetanus,  491 
Health,  electrical  tests  in,  42 
Hearing,  affections  of,  124 
in  leptomeningitis,  80 

center  for,  161 

electrical  testing  of,  47 


826 


INDEX. 


Hearing,  hallucinations  of,  650 
illusions  of,  653 
in  facial  paralysis,  119 
in  idiocy,  778 
testing  of,  63 
Heart  disease  in  etiology  of  insanity,  639 
Hebephrenic  insanity,  642 
Hematoma  auris,  673 

of  dura  mater,  72 
Hematomyelia,  330 
diagnosis  of,  332 
etiology  of,  330 
morbid  anatomy  of,  331 
prognosis  of,  332 
symptoms  of,  332 
treatment  of,  332 
Hemianesthesia  in  cerebral  hemorrhage, 

200 
Hemianopia,  double  homonymous,  expla- 
nation of  production  of,  97 
explanation  of  production  of,  96 
from  cerebral  hemorrhage,  200 
in  tumor  of  brain,  240 
Hemianopic  pupillary  reaction,  98 
Hemiatrophy,  facial,  from  disease  of  tri- 
facial nerve,  112 
Hemicordal  lesion,  effect  of,  on  sensation, 

51,  55 
Hemiplegia,  28,  201 

associated  movements  in,  201 
causes  of,  201 

circulatory  disturbances  in,  203 
complications  of,  203 
contractures  in,  201 
from  cerebral  hemorrhage,  199 
gait  in,  202 
hemianesthesia  in,  203 
hysterical,  556 
in  central  softening,  213 
in  cerebral  palsies  of  children,  248 
position  of  upper  extremity  in,  203 
Hemiplegic  gait,  202 

state,  201.     See  also  Hemiplegia 
Hemorrhage,  cerebellar,  205 
cerebral,  195 

apoplectic  state  in,  198 
clinical  forms  of,  205 
course  of,  204 
diagnosis  of,  206 
differential  diagnosis  of,  206 
etiology  of,  197 
hemiplegia  from,  201 
pathological  anatomy  of,  196 
prognosis  of,  207 
sensory  disturbances  in,  200 
symptoms  of,  198 
treatment  of,  208 
trophic  disturbances  in,  200 
extradural  spinal,  266 
extrapial,  74 

into  spinal  cord,  330.  See  Hematomyelia 
intrapial,  75 
meningeal,  74 
pial,  74 

spinal  meningeal,  266 
diagnosis  of,  267 
etiology  of,  266 


Hemorrhage,   spinal   meningeal,    morbid 
anatomy  of  267 
prognosis  of,  268 
symptoms  of,  267 
treatment  of,  268 
subdural  spinal,  266 
Hereditary  cerebellar  ataxia,  425 
cerebrospinal  syphilis,  452 
degeneracy,  612 
spastic  paraplegia,  431 
prognosis  of,  432 
symptoms  of,  432 
treatment  of,  432 
Heredity  in  etiology  of  insanity,  611 

neurotic,  importance  of,  18 
Herpes  labialis  in  leptomeningitis,  81 
Herpetiform  morphea,  482 
Heterophoria,  61 
Hiccup,  136 

Hide-bound  disease,  482 
Hip-roofed  palate,  622,  625 
Horizontal  localization  of  cord-lesions,  327 
Hot-baths  in  combined  sclerosis  of  cord, 
424 
in  leptomeningitis,  85 
in  multiple  neuritis,  315 
in  tubercular  leptomeningitis,  93 
Huntingdon's  chorea,  510 
disease,  510,  511 
diagnosis  of,  511 
etiology  of,  510 
morbid  anatomy  of,  510 
symptoms  of,  511 
Hutchinson's  teeth,  626 
Hydrocephalic  cry,  90 
Hydrocephalus,  255 

acute,  88.      See  Leptomeningitis,  tuber- 
cular 
course  of,  257 
diagnosis  of,  257 
etiology  of,  255 
external,  255 
internal,  255 
morbid  anatomy  of,  255 
prognosis  of,  258 
symptoms  of,  256 
treatment  of,  258 
Hydromyelocele,  354 
Hydrophobia,  492 
diagnosis  of,  494 
morbid  anatomy  of,  493 
symptoms  of,  493 
treatment  of,  494 
Hydrotherapy  in  exophthalmic  goiter,  481 

in  insanity,  687 
Hyoscin  in  epilepsy,  723 
in  etiology  of  insanity,  637 
in  mania,  700 
in  mental  disease,  689 
in  myoclonia,  513 
in  Parkinson's  disease,  519 
in  senile  dementia,  728 
in  torticollis,  141 
Hyoscyamin  in  epilepsy,  723 
in  etiology  of  insanity,  637 
in  mania,  700 
in  mental  disease,  689 


INDEX. 


Ill 


Hyperacusis,  124 
Hyperageusia,  65 
Hyperalgesia,  51 

from  lesions  of  spinal  cord,  325 

in  mental  disease,  654 

in  tabes  dorsalis,  401 
Hyperemia,  cerebral,  188.      See  Cerebral 

hyperemia 
Hyperestbesia,  51 

auditory,  63,  124,  125 

hysterical,  546 

in  mental  disease,  654 

in  multiple  neuritis,  304 
Hyperbedouia,  655 
Hyperostosis  cranii,  404 
Hyperthyroidation,  473 
Hypertrophies,  localized,  488 

unsymmetrical,  489 
Hypbedonia,  655 
Hypnotism,  598 

in  insanity,  692 

in  treatment  of  bysteria,  564 

methods  of  inducing,  599 

uses  of,  600 
Hypnotizing,  methods  of,  599 
Hypochlorhydria  in  insanity,  674 
Hypochondriacal  melancholia,  702,  705 

paralysis,  672 
Hypochondriasis,  665 

effect  of,  on  actions,  671 
Hypoglossal  nerve,  anatomical  conditions 
of,  143 

paralysis,  144 

spasm,  143 
Hypoglossus,  affections  of,  in  leptomenin- 
gitis, 80 
Hysteria,  538 

abonlia  in,  548 

accidents  in,  548 

achromatopsia  in,  542 

agraphia  in,  559 

amnesia  in,  547 

anesthesia  in,  540 
distribution  of,  543 
peculiarities  of,  544 

angina  pectoris  in,  559 

anorexia  in,  560 

anuria  in,  560 

aphonia  in,  559 

arc  de  cercle  in,  551,  552 

astasia  abasia  in,  557 

attacks  of  ecstacy,  554 
of  sleep,  554 

aura  of,  549 

cephalalgia  in,  558 

clonic  phase  of,  549 

contractures  of,  555 

cough  in,  557,  559 

course  of,  562 

coxalgia  in,  557 

dermographism  in,  561 

diagnosis  of,  562 

digestive  apparatus  in,  560 

dyschromatopsia  in,  542 

dysphagia  in,  560 

dyspnea  in,  559 

epileptoid  attacks  in,  554 


Hysteria,  epileptoid  period  of.  549 
etiology  of.  539 

fever  of,  551 
globus  in,  549,  55:; 
grand  attack  of.  549 
hearing  in,  541 
hemiplegia  in,  556 
hyperesthesia  in.  546 
impressionability  in,  54* 
in  etiology  of  insanity.  640 
modified  attacks  of,  553 
monoplegia  in.  556 
motor  accidents  of,  554 
movements  in,  546 
muscular  atrophy  in,  562 
nodding  spasm  in.  7,7,1 
paralyses  of,  555 
period  of  clownism,  549 

of  delirium  of.  553 

of  passional  attitudes,  552 
phase  of  contortions  of,  551 

of  grand  movements  of,  551 

of  resolution  of,  549 
ptosis  in,  556 

pulmonary  congestion  in,  559 
respiratory  affections  in,  554 
rhythmical  spasms  in,  557 
saltatory  chorea  in.  557 
sensory  accidents  of,  558 
simulation  in,  548 
smell  in,  541 

somnambulic  attacks  in,  554 
spasmogenic  zones  in,  546 
special  senses  in,  541 
spinal  irritability  in,  558 
stigmata  of,  540 

mental,  547 

motor,  546 

sensory,  540 
symptoms  of,  540 
syncopal  attacks  in,  554 
taste  in,  541 
tetanic  attacks  in,  554 
tics  in,  558 
tonic  phase  of,  549 
torticollis  in,  556 
trance  in,  554 
treatment  of,  563 

general,  563 

special,  564 
tremors  in,  557 
trophic  accidents  of,  561 
tympanites  in,  560 
urinary  apparatus  in,  560 
vasomotor  accidents  of,  561 
vertiginous  attacks  in,  553 
visceral  accidents  of,  559 

neuralgias  in,  559 
vision  in,  541 
Hysterical  anesthesia,  55,  540 

distribution  of,  543 

peculiarities  of,  544 
contractures,  555 
fever,  561 
heart,  562 
hyperesthesia,  546 
paralysis,  672 


828 


INDEX. 


Hysterical  pseudomeningitis,  558 

tics,  558 

tremors,  557 
Hysterogenic  point  or  zone,  546 
Hysteroneurasthenia,  535,  582 


Ice-bag  in  leptomeningitis,  85 
in  sciatic  neuritis,  294 
in  spinal  leptomeningitis,  265 

meningeal  hemorrhage,  268 
Ice  in  myelitis,  340 

in  tabes  dorsalis,  480 
Idea-association,  actions  induced  by  dis- 
orders of,  670 
disorders  of,  660 
testing  of,  678 
Ideas,  accelerated  flow  of,  662 
defective  evolution  of,  656 
diminished  flow  of,  662 
disorders  of,  655 
imperative,  667 
Idiocy,  amaurotic  family,  252,  724,  767 
attention  in,  780 
civility  and  politeness  in.  784 
classification  of,  767 
clothing  in,  815 

consciousness  and  personality  in,  793 
defined,  767 
destructiveness  in,  784 
diagnosis  of,  801 
education  of  attention  in,  809 

of  eye  in,  810 

of  hands  in,  811 

of  hearing  in,  810 

of  sense  of  touch  in,  809 

of  taste  and  smell  in,  -810 
food  in,  816 
general  etiology  of,  774 

pathological  anatomy  of,  793 

symptomatology  of,  777 

treatment  of,  808 
hearing  in,  778 
hydrotherapy  in,  815 
instincts  in,  782 
intelligence  in,  789 
language  in,  787 

manual  and  industrial  training  in,  813 
masturbation  in,  816 
medical  treatment  of,  815 
moral  training  in,  814 
morbid  movements  in,  778 
muscular  sensibility  in,  778 
organic  sensations  in,  780 
personality  in,  792 
physical  culture  in,  815 
physiognomy  in,  786 
play  in,  784 
preoccupation  in,  782 
prognosis  of,  805 
psychological  evolution  in,  793 
reflection  in,  782 
responsibility  in,  792,  793 
right-  and  left-handedness  in,  779 
sentiments  in,  784 
sight  in,  777 
smell  in,  778 


Idiocy,  special  aptitudes  in,  783 

tactile  pain  in,  778 

taste  in,  778 

teaching  of  cleanliness  in,  811 
language  in,  812 
to  walk  in,  811 

thermic  sensibility  in,  778 

voluntary  movements  in,  780 

will  in,  792 
Idiopathic  muscular  spasm,  37 

progressive  muscular  atrophy,  378.     See 
Progressive  muscular  atrophy 
Idiots,  education  of,  808 

savants,  774 
Iliac  point,  292 

Illness,  the  examination  of,  20 
Illusions,  653 

origin  of,  654 
Imbecility  defined,  608 
Imitation  in  etiology  of  insanity,  644 
Imperative  ideas,  667 
Inanition  delirium,  638 
Incoherence,  663 
Incoordination,  detection  of,  28 
Increased  motility,  29 
Incubus,  596 

Indicanuria  in  insanity,  675 
Indifferent  electrode,  41 
Indiscriminate  cord-lesions,  330 
Infantile  cerebral  palsies,  245.  See  Cerebral 

palsies  of  children 
Infantilism,  469 
Infection  neuroses,  490 
Infective  sinus  thrombosis,  222.    See  Sinus 

thrombosis 
Inflammation  of  brain,  226 

of  nerves,  271.     See  Neuritis 
Inflammatory  sinus  thrombosis,  222 
Ingravescent  apoplexy,  205 
Inherited  syphilis  as  a  predisposing  cause 

to  nervous  disease,  18 
Insane,  asylums  for,  681 

ear,  673 

isolation  of,  684 

moral  treatment  of,  691 
Insanity,  603 

accompanying  physical  diseases  of,  671 

acute,  treatment  of,  685 

age  in,  610 

alcohol  in  etiology  of,  635 

alternating,  711 

chronic  delusional,  743.     See  Paranoia 

circular,  711 
defined,  609 

classification  of,  605 

commotion,  640 

course  of,  679 

definition  of,  603 

diagnosis  of,  676 

diet  in,  686   s 

disorders  of  sensation  in,  649 

drugs  in,  689 

electrotherapy  in,  689 

epileptic,  609,  716 
acute  transitory,  719 
chronic,  720 
treatment  of,  721 


INDEX. 


Insanity,    etiology    of,    acute    infectious 
diseases  in,  638 

atheromatous  arteries  in,  639 

atropin  in,  637 

carcinoma  in,  (>'■'>'■) 

cocain  in,  637 

epilepsy  in,  639 

gastro-intestinal  disorders  in,  639 

genital  diease  in,  639 

hashish  in,  637 

head  injuries  in.  640 

heart  disease  in,  639 

hysteria  in,  640 

irritation  in,  6  1  I 

menopause  in,  643 

metallic  poisons  in,  637 

nephritis  in,  639 

nervous  exhaustion  in,  641 

organic  nervous  diseases  in,  640 

physiological  factors  in,  642 

puberty  in,  642 

puerperal  state  in,  643 

senility  in,  643 

syphilis  in,  638 

tuberculosis  in,  639 

various  poisous  in,  637 
examination  of  patient  in,  676 
general  etiology  of,  610 

symptomatology  of,  648 

treatment  of,  680 
hebephrenic,  642 
heredity  in,  611 
hydrotherapy  in,  687 
hypochlorhydria  in,  674 
massage  in,  686 
menstruation  in,  675 
moral  causes  of,  644 
morphin  in  etiology  of,  636 
motor  disorders  in,  672 
of  double  form,  711 
paralyses  in,  672 
prognosis  of,  680 
progressive  systematized,  743 
prophylaxis  of,  683     i 
reciprocal,  644 
reflex  disorders  oif,  673 
rest-cure  in,  686 
secretory  disorders  in,  673 
sensory  disorders  in,  672 
sex  in,  610 
strain  in,  635 
synonyms  of,  603 
temperature  changes  in,  675 
toxic  influences  in,  635 
trophic  disorders  in,  673 
urine  in,  674 
vascular  disorders  in,  676 
Insomnia,  593 
etiology  of,  593 
symptoms  of,  593 
treatment  of,  594 
Insular  sclerosis,  434.    See  Multiple  cerebro- 
spinal sclerosis 
Tntegument,  examination  of,  25 
Intention  tremor,  29 

in  multiple  sclerosis,  438 
Intermittent  mania,  698 


Intermittent  melancholia,  70"3 
Internal  capsule,  function  of,  174 

lesions  of,  effect  of,  on  sensation,  55 
motor  paths  in,  1"  I 
sensory  pal  lis  in,  175 
Intrapial  hemorrhage,  75 
Invasion  symptoms,  1  - 1 
Eodid  of  potassium  in  bronchial  asthma, 

L35 
Iodide  in  cerebral  hemorrhage,  209 

in  cerebrospinal  syphilis,  452 

in  Leptomeningitis,  35 

in  neuritis,  275 
Iodoform,    injection    of,  within   dura    in 

tubercular  leptomeningitis.  '■)'.', 
[ridoplegia,  61 
Iron  in  chorea,  509 

in  multiple  neuritis,  314 

in  neurasthenia,  538 
Irradiation,  657 
Irresein,  603 
Irritability,  659 
Irritative  brain-lesions,  180 
Irrsinn,  603 
Isolation  of  insane,  684 


Jacksoniax  convulsions,  30 
in  cerebral  softening,  213 

Jaw- jerk,  production  of,  32 

Jendrassik's  method  of  reinforcing  knee- 
jerk,  35 

Joints,  motility  of,  in  infantile  cerebral 
palsies,  249 
trophic  disorders  of.  38 

Judgment,  testing  of,  678 
weakness  of,  668 

Jumpers,  584 

Juvenile  variety  of  idiopathic  muscular 
atrophy,  386 


Kakideosis,  697 
Kakke,  296,  310 
Keel-shaped  skull,  617 
Knee-jerk,  34 

reinforced  by  Jendrassik's  method,  34, 
35 


Lability  of  phenomena,  660 
Labioglossolaryngeal  paralysis,  148.     See 

Polio-encephalitis  inferior  chronica 
Lalliug,  66 

Landholt's  rule  in  testing  diplopia,  106 
Landouzy-Dejerine    type     of     muscular 

atrophy,  387 
Landry's  paralysis,  344 

course  of,  346 

diagnosis  of,  347 

etiology  of,  344 

morbid  anatomy  of,  345 

prognosis  of,  347 

symptoms  of,  346 

treatment  of,  347 
Laryngeal  crises,  408 
epilepsy,  133 


830 


INDEX. 


Laryngeal  muscles,  action  of,  131 
nerves,  130 
palsies  in  tabes,  408 
paralyses,  131 
paralysis,  abductor,  131 
adductor,  131 
complete  bilateral,  33 
diagnosis  of,  131 
of  tensors,  132 
treatment  of,  133 
spasm,  133 
stroke,  408 
Larynx,  anesthesia  of,  133 
Latab,  584 

Latent  lesions  of  cerebral  cortex,  162 
Lateropulsion,  516 
Latbyrism,  432 
Law  of  regression,  656 
Lead-cap  headacbe,  531 
Lead  in  etiology  of  insanity,  637 
Lead-palsy,  308 
prognosis  of,  313 
treatment  of,  313 
Leg,  center  for  movements  of,  160 
Length-breadth  index,  617,  620 
Leontiasis  ossea,  464 
Leprous  neuritis,  310 
Leptocephalus,  616 
Leptomeningitis,  76 
acute  spinal,  262 
course  of,  264 
diagnosis  of,  264 
etiology  of,  262 
morbid  anatomy  of,  263 
prognosis  of,  265 
symptoms  of,  263 
treatment  of,  265 
chronic,  87 
spinal,  266 

morbid  anatomy  of,  266 
prognosis  of,  266 
symptoms  of,  266 
treatment  of,  266 
course  of,  82 
diagnosis  of,  82 
etiology  of,  76 
lumbar  puncture  in,  86 
pathological  anatomy, of,  78 
prognosis  of,  84 
symptoms  of,  79 
treatment  of,  84 
tubercular,  88 
course  of,  92 
diagnosis  of,  92 
etiology  of,  88 
pathological  anatomy  of,  88 
prognosis  of,  92 
symptoms  of,  90 
treatment  of,  93 
Lesions  of  one-half  of  the  cord,  effect  of, 
51 
of  spinal  cord,  anesthesia  in,  51 
Leukomyelitis  posterior,  390.     See  Tabes 

dorsalis 
Lids,  examination  of,  60 
Ligaments,  trophic  disorders  of,  38 
Lightning  pains  in  tabes  dorsalis,  399 


Limbs,  anomalies  of,  632 
Limp  chorea,  508 
Lingual  spasm,  143 
Lipoma  of  brain,  236 
Lipomatosis,  symmetrical,  488 
Lips,  anomalies  of,  626 
Little's  disease,  252 
Local  asphyxia,  484 

convulsions,  30 

death,  484 

syncope,  484 
Localization,  cerebral,  155 

general  considerations  of,  155 

in  cerebral  cortex,  155 

motor  cortical,  158 

of  cord  lesion,  horizontal,  327 
vertical,  323 

of  lesions  of  cauda  equina,  328 

sensory  cortical,  160 

spinal,  316 
Localized  hypertrophies,  488 

symptoms,  182 
Lockjaw,  490 
Locomotor  ataxia,  progressive,   390.     See 

Tabes  dorsalis 
Logorrhea,  659 
Lumbar  points,  292 

puncture  in  leptomeningitis,  86 
in  spinal  leptomeningitis,  265 
in  tubercular  meningitis,  93 
Lyssa,  492 
Lyssophobia,  494 


Mackocephalus,  616 
Macroglossus,  626 
Make  of  current,  42 
Maladie  des  tics,  583,  668 
Mandibular  muscles,  paralysis  of,    from 
disease  of  trifacial  nerve,  111 

reflex,  32 
Mania,  694 

acute  delirious,  697 

cbronic,  698 

course  of,  698 

definition  of,  694 

dementia  from,  698 

diagnosis  of,  699 

etiology  of,  694 

gravis,  697 

intermittent,  698 

mental  symptoms  of,  694 

mitis,  697 

pathology  of,  698 

periodical,  697 

physical  symptoms  of,  697 

prognosis  of,  699 

recurrent,  698 

transitory,  697 

treatment  of,  699 

varieties  of,  697 
Marantic  sinus  thrombosis,  221.    See  Sinus 

thrombosis 
Massage  in  anterior  poliomyelitis,  363 

in  combined  sclerosis  of  cord,  424 

in  exophthalmic  goiter,  481 

in  facial  paralysis,  122 


INDEX. 


831 


Massage  in  infantile  cerebral  palsies,  254 

in  insanity,  686 

in  Landry's  paralysis,  347 

in  multiple  neuritis,  315 

in  myelitis,  340 

in  neuritis,  275 
of  brachial  plexus,  288 

in  sciatic  neuritis,  295 

in  spinal  progressive  muscular  atrophy, 
378 

in  tabes  dorsalis,  418 
Massive  type  of  acromegalia,  462 
Mastication,  center  for,  160 
Masticatory  paralysis,  110 

spasm,  110 
Mastoid  disease,  importance  of,  64 
Masturbation  in  insanity,   treatment  of, 

693 
Mathieu's  hand-dynamometer,  27 
Maximal  points  of  pain,  55 
Median  nerve,  lesions  of,  282 
Medulla  oblongata,   symptoms  of  lesions 

of,  178 
Megalocephalie,  464 
Megalodactyly,  632 
Megalomelus.  632 
Melancholia,  700 

acute  hallucinatory,  705 

agitata,  663,  704 

attonita,  663,  704 

catatonic,  705 

course  of,  707 

definition  of,  700 

diagnosis  of,  708 

etiology  of,  700 

hypochondriacal,  702,  705 

intermittent,  707 

mental  symptoms  in,  701 

passiva,  663,  704 

pathological  anatomy  of,  707 

periodical,  707 

physical  symptoms  of,  704 

prognosis  of,  709 

recurrent,  707 

treatment  of,  709 

varieties  of,  704 
Memory  defects,  actions  induced  by,  669 

disorders  of,  661,  662 

importance  of,  in  diagnosis,  23 

testing  of,  678 
Memory-pictures,  disorders  of,  655,  656 
Meniere's  disease,  126.     See  Aural  vertigo 
Meningeal  hemorrhage,  74 

spinal,  266 
Meninges,  cerebral,  70 

spinal,  tumors  of,  350 
Meningitis,  acute  cerebral,  76.     See  also 
Leptomeningitis  and  Pachymeningitis 

basilar,  88.     See  Meningitis,  tubercular 

cerebral,  syphilitic,  444 
symptoms  of,  446 

cerebrospinal,  76.     See  Leptomeningitis 

chronic  infantile,  87 

purulent,  76.     See  Leptomeningitis 

spinal,  260 

syphilitic  spinal,  450 
Meningocele,  354 


Meuingomyelitis,  spinal,  260 

syphilil  Lc,  450 
Meningomyelocele,  354 

Menopause  in  etiology  of  insanity,  643 
Menstruation  in  insanity,  675 
.Mental  condition  of  patient,  examination 
of,  22 

diseases,  603 

disturbance  as  a  cerebral  symptom,  183 

strain.  63  I 

symptoms  in  tumor  of  brain,  238 

torticollis,  141,  584 
Meralgia,  288 

Mercurial  inunctions  in  acute  spinal  lepto- 
meningitis, 265 
in  neuritis,  275 
Mercury  in  cerebrospinal  syphilis,  452 

in  etiology  <>f  insanity,  637 

in  hydrocephalus,  258 

in  leptomeningitis,  85 

in  sciatic  neuritis,  295 
Merycism,  140 
Mesocephalic  head,  615 
Metallic  poisons  in  etiology  of  insanity, 

637 
Metatarsal gi a,  290 
Microcephalus,  616 
Micromania,  665 
Middle-ear  disease,  64 
Migraine,  577 

course  of,  579 

diagnosis  of,  580 

etiology  of,  577 

pathology  of,  580 

prognosis  of,  580 

symptoms  of,  577 

treatment  of,  580 
Mimic  spasm,  583 
Mind-blindness,  67,  167 

lesion  causing,  161 
Mirror-speech,  68 
Mirror-writing,  68 
Modal  change,  45 
Mogigraphia,  522 
Monocular  diplopia,  61 
Monomania,  609,  743 
Monoplegia,  28 

in  tumor  of  brain,  240 
Moods,  657 
Moral  causes  of  insanity,  644 

treatment  of  insane,  691 
Morbus  sacer,  565 
Morel  ear,  628,  629 
Morphin  in  caisson  disease,  349 

in  chorea,  509 

in  etiology  of  insanity,  636 

in  leptomeningitis,  84 

in  mental  disease,  689 

in  migraine,  581 

in  neuralgia,  590 

in  Raynaud's  disease,  485 

in  sciatic  neuritis,  295 

in  tabes  dorsalis,  420 

in  tetanus,  492 
Morphological  stigmata  of  degeneracy,  21 
Morton's  disease,  290 
Morvan's  disease,  369 


832 


INDEX. 


Motility,  27 
increased,  29 
reduced,  27 
Motor  aphasia,  168 

areas  of  pain,   localization  of,  by  elec- 
tricity, 47 
disorders  in  insanity,  672 
function,  anomalies  of,  633 
neuroses,  510 

points  of  face  and  neck,  40 
of  lower  extremity,  43,  44,  45 
of  upper  extremity,  41,  42 
tracts  of  brain,  174-180 
Movement,  hallucinations  of,  650 
Movements,  associated,  30 

postplegic,  30 
Multiple  abscesses  of  brain,  230 
cerebrospinal  sclerosis,  434 
bulbar  symptoms  of,  440 
cerebral  symptoms  of,  440 
course  of,  440 
diagnosis  of,  441 
etiology  of,  434 
forms  of,  440 
intention  tremor  in,  438 
morbid  anatomy  of,  436 
motor  features  of,  437 
prognosis  of,  442 
sensory  symptoms  of,  439 
sympt07ns  of,  437 
treatment  of,  442 
trophic  disturbances  in,  440 
visual  disturbances  in,  440 
neuritis,  296 
neuromata,  276 

paralyses  of  cranial  nerves,  145 
Muscles,  electrical  testing  of,  39 
testing  of  power  of,  27,  28 
trophic  disorders  of,  38 
Muscular  sense,  testing  of,  50 
system,  examination  of,  27 
Musculospiral  nerve,  lesions  of,  280 
Mutism  in  hysteria,  66 
Myelinic  neuromata,  276 
Myelitis,  333 

acute  bulbar,  154 
syphilitic,  451 
atrophy  in,  337 
central,  334 
course  of,  338 
diagnosis  of,  338 

differential,  339 
disseminated,  334 
etiology  of,  334 
morbid  anatomy  of,  334 
motor  symptoms  of,  336 
paraplegia  in,  340 
prognosis  of,  339 
reflexes  in,  337 
sensory  symptoms  of,  336 
symptoms  of,  335 
transverse,  334 
treatment  of,  339 
trophic  changes  in,  337 
Myelocele,  354 
Myoclonia,  511 
diagnosis  of,  512 


Myoclonia,  etiology  of,  512 

prognosis  of,  513 

symptoms  of,  512 

treatment  of,  513 
Myoclonus,  511 
Myoidema,  37,  301 
Myopathic  facies,  380 
Myopathy,  primitive  progressive,  378 
Myositis  in  multiple  neuritis,  299 
Myotonia,  31,  519.     See  lliomsen'' s  disease 

congenita,  519 

family,  519 
Myriachit,  584 
Mysophobia,  667 
Myxedema,  465 

acquired,  of  adults,  465 

congenital,  467 

etiology  of,  470 

morbid  anatomy  of,  470 

operative,  467 

treatment  of,  471 
Myxedematous  idiocy,  467 

retardation,  469 


Narcolepsy,  597 

Narrow- headedness,  616 

Naso-occipital  arc,  617,  620 

Nasus  aduncus,  627 

Negation,  delusion  of,  666 

Nephritic  crises,  407 

Nephritis  in  etiology  of  insanity,  639 

Nerve,  circumflex.     See  Circumflex  nerve 

divided,  changes  in,  269 
regeneration  of,  270 
symptoms  of,  269 
treatment  of,  270 

division  of,  269 

electric  tests  of,  in  health,  42 

-grafting  for  neuromata,  277 

median.     See  Median  nerve 

musculospiral.     See  Musculosjnral  nerve 

phrenic.     See  Phrenic  nerve 

-stretching  for  neuromata,  278 

suprascapular.     See  Suprascapular  nerve 

suture  of,  270 

thoracic.     See  Thoracic  nerve 

-trunk,  lesion  of,  location  of  anesthesia 
in,  51 

-tumors,  275.     See  also  Neuromata 

ulnar.     See  Ulnar  nerve 
Nerves,  cutaneous  distribution  of,  52,  53 

electrical  testing  of,  39 

inflammation  of,  271.     See  Neuritis 

of  lower  extremity,  lesions  of,  288 

of  trunk,  lesions  of,  288 

spinal.     See  Spinal  nerves 
Nervous  coughs,  134 

diseases,  functional,  456 

organic,  in  etiology  of  insanity,  640 

dyspepsia,  140 

exhaustion,  528.     See  Neurasthenia 
in  etiology  of  insanity,  641 

prostration,  528.     See  also  Neurasthenia 

system,  syphilis  of,  442 
Neuralgia,  586 

characters  of,  587 


INDEX. 


833 


Neuralgia,  conditions  favoring,  587 
in  branches  of  trifacial,  113 
in  insanity,  672 
pathology  of,  588 
treatment  of,  589 
trifacial,  589 
varieties  of,  588 
Neurasthenia,  528 
circulatory  disorders  in,  532 
course  of,  535 
diagnosis  of,  535 
disorders  of  hearing  in,  532 

of  smell  in,  532 

of  taste  in,  532 
etiology  of,  528 
fear  in,  534 
forms  of,  535 

gastro- intestinal  disorders  in,  532 
general  state  in,  534 
genital  disorders  in,  533 
headache  in,  530 
mental  disturbances  in,  533 
motor  disorders  of,  530 
nosophobias  in,  534 
photophobia  in,  532 
prognosis  of,  536 
secretory  disorders  in,  533 
sensory  disturbances  in,  530 
sleep  in,  534 
symptoms  of,  529 
tenderness  in,  531 
traumatic,  582 
visual  disturbances  in,  531 
Neuritis,  271 
adventitious,  271 
alcoholic,  308 
diagnosis  of,  274 
etiology  of,  271 
leprous,  310 
migrans,  272 
morbid  anatomy  of,  271 
multiple,  296 

accommodation  in,  305 

alcoholic  form  of,  308 

course  of,  307 

diagnosis  of,  311 

of  the  toxic  cause  of,  312 

differential   diagnosis  of,  from    hys- 
teria, 312 
from  locomotor  ataxia,  311 
from  myelitis,  312 
from  poliomyelitis,  311 

electrical  changes  in,  301 

etiology  of,  296 

from  lead  poisoning,  308 

general  conditions  in,  305 

lesions  in  muscles  in,  298 
in  nerves  in,  297 
of  brain  in,  298 
of  spinal  cord  in,  298 

morbid  anatomy  of,  297 

motions  of  eyes  in,  304 

nutrition  in,  305 

prognosis  of,  312 

pupils  in,  304 

reflexes  in,  303 

special  forms  of,  307 
53 


Neuritis,  multiple,  symptoms  of,  299 
mental,  305 
motor,  in,  299 
muscular,  299 
ocular,  304 
sensory,  303 
treatment  of,  313 
trophic  conditions  in,  305 
vision  in,  304 
of  brachial  plexus,  286 
causes  of,  286 
diagnosis  of,  287 
prognosis  of,  287 
symptoms  of,  286 
treatment  of,  287 
of  branches  of  trifacial,  113 
optic,  100 

as  a  symptom,  183 
parenchymatous,  271 
prognosis  of,  274 
sciatic,  290 
causes  of,  291 
diagnosis  of,  293 
double,  293 

morbid  anatomy  of,  291 
symptoms  of,  291 
tender  points  in,  292 
treatment  of,  294 
symptoms  of,  272 
syphilitic,  452 
treatment  of,  274 
Neuroma  of  brain,  236 
Neuromata,  275 
amputation,  276 
amyelinic,  276 
cellular,  276 
diagnosis  of,  277 
dolorosa,  276 
etiology  of,  276 
fibrillar,  276 
ganglion,  276 
multiple,  276 
myelinic,  276 
prognosis  of,  277 
symptoms  of.  277 
traumatic,  276 
treatment  of,  277 
Neuroretinitis,  100 
Neuroses,  456 
classification  of,  456 
fatigue,  521 

following  traumatism,  581 
infection,  490 
motor,  510 

occupation,  20,  521,  527 
Neurotabes,  416 
Neurotic  heredity  as  a  factor  in  diagnosis, 

18 
Nightmare,  596 
Night-terrors,  596 

Ninth  nerve.     See  Glossox>liaryngeal  nerve 
Nitrite  of  amyl  in  bronchial  asthma,  136 

in  tetanus,  492 
Nitroglycerin  in  migraine,  580 

in  sciatic  neuritis,  295 
Nocturnal  enuresis,  596 
epilepsy,  571 


834 


INDEX. 


Nodding  spasm  in  hysteria,  557 

Normal  child,  development  of  the  faculties 

of,  795 
Nose,  anomalies  of,  627 
Nutrition,  abnormal  variations  in,  37 
Nystagmus,  108 


Oblique  line,  163 

Obturator  nerve,  lesions  of,  288 

Occupation  neuroses,  20,  521,  527 

predisposing  to  nervous  disease,  20 
Ocular  muscle,  spasms  of,  108 

muscles,  action  of,  103 

nerves,  anatomical  considerations  of,  102 
diseases  of,  102 

palsies,  104 
causes  of,  107 
diagnosis  of,  104 
location  of  lesion  in,  106 
treatment  of,  109 
Olfactory  nerve,  diseases  of,  94 
Oligodactyly,  632 
Oligomelus,  632 
Oliguria  in  insanity,  674 
Operative  myxedema,  467 
Ophthalmoplegia  externa,  61 

interna,  61 

progressive,   146.     See  Polio-encephalitis 
superior  chronica 
Ophthalmoscope,  importance  of,  to  neurol- 
ogist, 61 
Opisthognathism,  618 
Opisthotonos  in  cerebellar  disease,  179 
Opium-bromid  treatment  in  epilepsy,  722 
Opium  in  epilepsy,  576 

in  insanity,  689 

in  mania,  700 

in  melancholia,  710 

in  paralytic  dementia,  742 

in  Parkinson's  disease,  519 

in  torticollis,  141 
Optic  nerve,  anatomy  of,  95 
atrophy  of,  101 
diseases  of,  95 
lesions  of,  95-100 

neuritis  as  a  symptom,  183 
in  tumors  of  brain,  239 

thalami,  function  of,  176 

thalamus,  lesions  of,  99,  176 

tract,  lesions  of,  96-100 
Orbits,  asymmetry  of,  621 
Orthognathism,  618 
Osteo-arthropathie  hypertrophiante  pnen- 

mique,  463 
Osteo-arthropathy,   pulmonary   hypertro- 
phic, 463 
Osteoma  of  brain,  236 
Othematoma,  673 
Oxaluria  in  insanity,  674 
Oxycephalus,  616 


Pachydermatous  cachexia,  465 
Pachymeningitis,  72 

cervicalis  hypertrophica,  261 

externa,  72 


Pachymeningitis,  externa  spinalis,  260 

hsemorrhagica,  72 

interna,  72 
course  of,  73 
diagnosis  of,  74 
etiology  of,  72 
pathological  anatomy  of,  72 
spinalis,  261 
symptoms  of,  73 
treatment  of,  74 
Pain,  areas  of,  relation  to  visceral  disease, 
56 

as  a  cerebral  symptom,  184 

as  a  symptom,  55 

description  of,  by  patients,  60 

in  angina  pectoris,  138 

in  brain-disease,  60 

in  myelitis,  335 

in  neuritis,  272 

in  sciatic  neuritis,  291 

in  spinal  tumors,  352 

in  syphilitic  meningitis,  450 

in  tabes  dorsalis,  399 

maximal  points  of,  55 

sense,  testing  of,  49 
Palate,  asymmetrical,  622,  625 

cleft,  623 

deformities  of,  621 

dome-shaped,  622,  624 

flat-roofed,  622,  624 

gothic,  622,  623 

hip-roofed,  622,  625 

with  horseshoe  arch,  622,  623 
Palpebral  reflex,  32 
Palpitation,  cardiac,  137 
Palsies,  combined,  of  nerves  of  arm,  285 

in  tabes  dorsalis,  399 

sleep,  598 
Palsy,  Bell's,  116 

scriveners',  522 

wasting,  371 
Panophthalmitis  in  leptomeningitis,  80 
Papilla,  optic,  diseases  of,  100 
Papillitis,  100 

in  tumor  of  brain,  239 
Papilloneuritis,  100 
Paradoxical  contraction,  36 
Parageusia,  65 
Paragraphia,  67 
Paraldehyd  in  mania,  700 

in  mental  disease,  690 

in  senile  dementia,  728 
Paralyses  of  hysteria,  555 
Paralysis,    acute    ascending,    344.       See 
Landry'1 s  paralysis 

agitans,  514.     See  Parkinson's  disease 

Brown-Sequard,  cord-lesion  in,  51,  55 

bulbar,  asthenic,  153 

cerebral,  of  children,  245 

chronic  nuclear  ocular,  146.     See  Polio- 
encephalitis superior  chronica 

diphtheric,  309 

facial,  116.     See  Facial  paralysis 

from  brain-abscess,  231 

from  cerebral  hemorrhage,  214 

from  cord-lesion,  323 

hypoglossal,  144 


INDEX. 


835 


Paralysis  in  anterior  poliomyelitis,  359 
in  cerebral  softening,  213,  214 
in  insanity,  672 
in  multiple  neuritis,  299 
in  myelitis,  336 
in  syphilitic  meningitis,  450 
in  tabes  dorsal  is,  :;!)!) 
labioglossolaryngeal,    148.      See  Polio- 

encephalitis  inferior  chronica 
Landry's,  344 

laryngeal,  131.     See  Laryngeal  paralysis 
masticatory,  110 
multiple,  of  cranial  nerves,  145 
ocular,  101.     .See  Ocular  palsy 
of  anterior  crural  nerve,  288 
of  auditory  nerve,  125 
of  circumflex  nerve,  280 
of  facial  nerve,  116 
of  median  nerve,  282 
of  musculospiral  nerve,  280 
of  obturator  nerve,  288 
of  phrenic  nerve,  278 
of  posterior  thoracic  nerve,  279 
of  sciatic  nerve,  289 
of  spinal  accessory  nerve,  142 
of  superior  gluteal  nerve,  289 
of  suprascapular  nerve,  279 
of  tongue,  144 
pharyngeal,  130 

progressive   bulbar,   148.       See    Polio- 
encephalitis inferior  chronica 
pseudobulbar,  153 
pseudohypertrophic,  386 
syphilitic  spinal,  451 
ulnar,  284 
Paralytic  chorea,  508 
dementia,  724,  730 

defiuition  of,  730 

diagnosis  of,  739 

differentiation   of,    from   alcoholism, 
739 
from  cerebrospinal  syphilis,  740 
from  multiple  sclerosis,  741 
from  neurasthenia,  739 

duration  and  prognosis  of,  738 

etiology  of,  730 

mental  symptoms  of,  733 

pathological  anatomy  of,  741 

physical  symptoms  of,  733 

prodromal  period  of,  732 

symptomatology  of,  732 

terminal  period  of,  738 

treatment  of,  742 
Paramimia,  67,  167 
Paramyoclonus,  511 

multiplex,  512 
Paramyotonia,  congenital,  520 
Paranoia,  609,  743 
course  and  prognosis  of,  766 
definition  of,  743 
erotica,  747 
etiology  of,  744 
expansive  period  of,  747 
from  mania,  698 
hallucinatoria  acuta,  743 

chronica,  743 
inventoria,  747 


Paranoia,  morbid  anatomy  of.  766 
persecutory  period  of.  745 
prodromal  period  of,  744 
querulans,  747 
reformatoria,  747 
religiosa,  747 

secondaria  melancholica,  708 
simplex  acuta.  743 

chronica.  74:; 

symptomatology  of,  744 

treatment  of,  7(10 

varieties  of,  74:; 

Paraphasia,  166,  169 

Paraphrasia,   67 

Paraplegia,    28,     340.        See     Paraph  gic 
state 
ataxic,  421 

syphilitic,  4.11 
from  hematoiuyelia,  332 
hereditary  spastic,  431.     See  Hereditary 

spastic  paraplegia 
in  myelitis,  340 
in  spinal  tumors,  352 
Paraplegic  gait,  342 
state,  attitude  in,  343 
etiology  of,  341 
gait  in,  342 
in  myelitis,  340 
prognosis  of,  343 
reflexes  in,  .343 
symptoms  of,  341 
treatment  of,  344 
Parasyphilitic  diseases,  454 
acquired,  454 
hereditary,  455 
nervous  disease,  442 
Parenchymatous  neuritis,  271 
Paresthesia  in  multiple  neuritis,  303 

in  neuritis,  272 
Paresthesias,  51 
Parkinson's  disease,  514 
course  of,  518 
diagnosis  of,  518 
etiology  of,  514 
mental  state  in,  518 
morbid  anatomy  of.  514 
muscular  rigidity  in,  515 
palsy  in,  518 

sensory  disturbances  in,  518 
symptoms  of,  515 
treatment  of,  519 
trembling  in,  516 
Past  illness,  investigation  of,  19 
Patellar  point,  292 

reflex,  34 
Patient,  antecedents  of,  18 

examination  of,  17-69 
Pavor  nocturnus,  596 
Pellagra,  433 

Percussion  in  brain  disease,  184 
Peri-arteritis,  cerebral,  190 
Perineuritis,  271 
Periodical  mania,  697 
melancholia,  707 
swelling,  486 
Peripheral  nerves,  trophic  diseases  of,  38 
paralysis  in  insanity,  672 


836 


INDEX. 


Pernicious  anemias,  lesions  of  spinal  cord 

from,  350 
Peroneal  nerve,  lesions  of,  289 
variety  of  idiopathic  muscular  atrophy, 
386 
Persecution,  delusion  of,  665 
Personal  history,  19 
Peterson's  calipers,  618,  619 
Petit  mal,  571 
Pharyngeal  crises,  408 
paralysis,  130 
reflex,  33 
spasm,  130 
Phenacetin  in  acromegalia,  463 

in  epilepsy,  576 
Phocomelus,  632 
Phosphaturia  in  insanity,  674 
Photophobia  as  a  symptom,  60 

in  leptomeningitis,  80 
Phrenic  nerve,  lesions  of,  278 
Physical  examination,  23 

strain,  634 
Physiognomy  of  patient,  21 
Physiological  factors  in  etiology  of  insan- 
ity, 642 
Pia  mater,  670 

inflammation  of,  76.    See  Leptomenin- 
gitis 
visceral,  70 
Pial  hemorrhage,  74 

space,  70 
Pilocarpin  in  aural  vertigo,  129 

in  nervous  deafness,  126 
Plagiocephalus,  617 
Plantar  nerve,  external,  lesions  of,  290 
internal,  lesions  of,  290 
points,  292 
reflex,  36 
Platicephalus,  616 

Pleurothotonos  in  cerebellar  disease,  179 
Pneumococcns  in  leptomeningitis,  77 
Pneumogastric  nerve.     See  Vagus 
Polar  change,  45 

Polio-encephalitis,  combined  forms  of,  154 
inferior  chronica,  148 
course  of,  152 
diagnosis  of,  152 
etiology  of,  149 
morbid  anatomy  of,  149 
symptoms  of,  149 
treatment  of,  154 
superior,  acute,  148 
superior  chronica,  146 
course  of,  147 
diagnosis  of,  148 
etiology  of,  146 
pathological  anatomy  of,  146 
symptoms  of,  146 
treatment  of,  148 
Poliomyelitis,  acute  anterior,  356 
course  of,  361 
deformity  in,  360 
diagnosis  of,  361 
etiology  of,  356 
forms  of,  361 
morbid  anatomy  of,  356 
prognosis  of,  362 


Poliomyelitis,    acute  anterior,  symptoms 
of,  359 
treatment  of,  362 
chronic,  371 
Polydactyly,  632 
Polymastia,  632 

Polyneuritis,  296.     See  Neuritis,  multiple 
Polyuria  in  insanity,  674 
Pons  Varolii,  function  of,  177 

symptoms  of  lesions  of,  177 
Popliteal  nerve,  external,  lesions  of,  289 
internal,  lesions  of,  290 
point,  292 
Posterior  columns  of  cord,  effect  of  lesions 
of,  327 
horn  of  cord,  effect  of  lesions  of,  327 
roots  of  cord,  effect  of  lesions  of,  327 
spinal  arteries,  322 
Posterolateral  sclerosis,  421.      See  Com- 
bined sclerosis  of  cord 
Postplegic  movements,  30 
Precordial  anxiety,  658 

fright,  658 
Present  condition  of  patient,  23 
Pressure  sense,  testing  of,  49 
Priinare  Verriicktheit,  609 
Primary  dementia,  609,  724,  728 
Prodromes,  epileptic,  568 
Prognathism,  618 

Progressive  bulbar   paralysis,    148.     See 
Polio- encephalitis  inferior  chronica 
general   paralysis,   730.     See   Paralytic 

dementia 
locomotor  ataxia,  390.     See  Tabes  dor- 

salis 
muscular  atrophy,  370 
idiopathic,  378 
course  of,  384 
etiology  of,  379 
morbid  anatomy  of,  379 
prognosis  of,  387 
symptoms  of,  380 
treatment  of,  387 
varieties  of,  385 
spinal,  370 
course  of,  377 
diagnosis  of,  377 
differential  diagnosis  of,  377 
etiology  of,  371 
morbid  anatomy  of,  372 
prognosis  of,  377 
symptoms  of,  373 
treatmeut  of,  378 
varieties  of,  376 
with   cord  lesions.     Same  as  Pro- 
gressive muscular  atrophy,  spinal 
without  cord   lesions.       Same    as 
Progressive  muscular  atrophy,  iodi- 
pathic 
dystrophy,  378 
ophthalmoplegia,  146.  See  Polio-enceph- 
alitis superior  chronica 
spastic  ataxia,  421.  See  Combined  sclero- 
sis of  spinal  cord 
systematized  insanity,  743.     See  Para- 
noia 
Projectile  vomiting  as  a  symptom,  183 


INDEX. 


xr.l 


Propulsion,  516 

Psaminonia,  236 

Pseudo-apraxia,  664 

Pseudo-ataxia,  664 

Pseudoataxie  cerebelleuse,  425 

Pseudobulbar  paralyses,  153 

Pseudochorea,  664 

Pseudodementia,  660 

Pseudohypertrophic  paralysis,  386 

Pseudomeningitis,  hysterical,  588 

Pseudoparaphrasia,  663 

Pseudoparesis,  syphilitic,  448 

Pseudotabes,  416 

Psychic  degeneration  of  epileptics,  717 
equivalent  of  epileptic  attack,  572 

Psychopathy,  603 

Psychosis,  603 

Psychotherapy,  691 

Ptosis  as  a  symptom,  60 
sleep,  598 

Puberty  in  etiology  of  insanity,  642 

Puerperal  state  in   etiology   of  insanity, 
643 
tetanus,  491 

Pulmonary  branches  of  vagus,  affections 
of,  134 
hypertrophic  osteo-arthropathy,  463 

Pulse  in  leptomeningitis,  81 
in  polio-encephalitis  inferior  chronica, 

151 
in  spinal  leptomeningitis,  264 
in  tubercular  leptomeningitis,  90 

Pupil,  irregularities  of,  61 

Pupillary  reflex,  32 

Pupils,  condition  of,  in  leptomeningitis, 
80 
in  multiple  neuritis,  304 

Purulent  meningitis,  76.    See  Leptomenin- 
gitis 

Pyramidal  tracts,  effect  of  lesions  of,  327 


Qualitative  change,  45 
Quincke's  disease,  486 

lumbar  puncture  in  spinal  leptomenin- 
gitis, 205 
Quinin  in  aural  vertigo,  129 
in  chorea,  509 
in  multiple  neuritis,  314 

sclerosis,  442 
in  neuralgia,  590 


Rabies,  492 

Raptus  melancholicus,  704,  705 

Raynaud's  disease,  484 

course  and  prognosis  of,  485 

diagnosis  of,  485 

etiology  of,  484 

symptoms  of,  484 

treatment  of,  485 
Reaction,  hemianopic  pupillary,  98 
of  degeneration,  45 

in  facial  paralysis,  118 

partial,  46 
Reciprocal  insanity,  644 
Rectus  clonus,  35 


Reel  us  reflex,  35 
Recurrent  mania,  698 

melancholia,  707 
Red  cerebral  softening,  211 
Reduced  motility,  27 
Referred  sensation,  50 
Reflected  tone,  657 
Reflex,  abdominal.  34 

Achilles  tendon,  36 

anal,  86 

bulbocavernous,  407 

ciliary,  32 

cremasteric,  36 

disorders  in  insanity,  673 

epigastric,  34 

mandibular,  32 

palpebral,  32 

patellar,  34 

pharyngeal,  33 

plantar,  36 

pupillary,  32 

rectus,  35 

sphincter,  36 

triceps,  33 

virile,  407 
Reflexes,  31 

in  anterior  poliomyelitis,  359 

in  lesions  of  spinal  cord,  325 

in  multiple  neuritis.  303 

in  myelitis,  337 

in  paraplegic  state,  343 

in   progressive  muscular  atrophy  with 
cord  lesions,  376 

in  spinal  tumors,  352 

in  tabes  dorsalis,  402 

of  the  upper  extremity,  33 
Refraction,  errors  of,  importance  of,  61 
Refusal  of  food,  management  of,  693 
Regeneration  of  a  divided  nerve,  270 
Regression,  law  of,  656 
Residence,  importance  of,  20 
Respiration  in  leptomeningitis,  82 

in  tubercular  leptomeningitis,  90 
Respiratory  organs,  examination  of,  24 
Rest-cure,  686 
Rest  in  multiple  neuritis,  314 

in  neuritis,  274 

in  sciatic  neuritis,  294 
Retina,  diseases  of,  100 
Retinitis,  100 
Retropulsion,  516 
Reversion,  612 

Rheumatism,  relation  of,  to  chorea,  500 
Right-handedness,  cause  of,  158 
Rigidity  in  tubercular  leptomeningitis,  90 

muscular,  in  leptomeningitis,  70 
Rinne's  test,  63 

Robertson  pupillary  sign  in  tabes,  403 
Romberg,  sign  of,  397 

symptoms,  29 
Rumination,  140 


Sagittal  line,  163 

Salicylate  of  soda  in  auto-intoxication,  689 
Salicylates  in  anterior  poliomyelitis,  363 
in  facial  paralysis,  122 


838 


INDEX. 


Salicylates  in  Landry's  paralysis,  347 
Salol  in  auto-intoxication,  689 

in  epilepsy,  576,  723 

in  multiple  neuritis,  314 

in  myelitis,  340 
Saltatory  chorea  in  hysteria,  557 
Sarcoma  of  brain,  234 
Scanning  speech,  66 
Scaphocephalus,  617 
Sciatic  nerve,  great,  lesion  of,  289 

neuritis,  290.     See  Neuritis 

scoliosis,  292 
Sclerodactylie,  482 
Scleroderma,  482 

etiology  of,  482 

symptoms  of,  483 

treatment  of,  484 
Scleroma  adultorurn,  482 
Sclerose  en  plaques,  434 
Scleroses  of  spinal  cord,  combined,  421 
Sclerosis,  amyotrophic  lateral,  371 

disseminated,  434 

multiple  cerebrospinal,  434.     See  Mul- 
tiple cerebrospinal  sclerosis 

of  posterior  columns  of  cord,  390.     See 
Tabes  dorsalis 

of  spinal  cord  from  vegetable  intoxi- 
cants, 432 

posterolateral,  421.     See  Combined  scle- 
rosis 

sciatic,  292 
Scotch  douche,  688 
Scotoma,  central,  98 
Scotomata,  62 
Scriveners'  palsy,  522 
Secondary  dementia,  609,  724,  725.     See 

Dementia 
Secretory  disorders  in  insanity,  673 
Sedatives  in  leptomeningitis,  84 
Senile  chorea,  512 

dementia,  724,  726.     See  Dementia 
Senility  in  etiology  of  insanity,  643 
Sensation,  disorders  of,  in  insanity,  649 
intensity  of,  654 
qualitative,  649 
tone  of,  654 

general  consideration  of,  48 

referred,  50 

testing  and  examination  of,  48 
Sensibility,  hallucinations  of,  650 

illusions  of,  654 
Sensory  conditions,  48 

disorders,  actions  indorsed  by,  669 
in  insanity,  672 

disturbances  from  brain-lesion,  182 

function,  anomalies  of,  633 

tone,  disorders  of,  654 
Seventh  cranial  nerve.     See  Facial  nerve 
Sex  in  etiology  of  insanity,  610 
Shaking  palsy,  514 

Shoulder,  center  for  movements  of,  160 
Sight,  affections  of,  in  tubercular  lepto- 
meningitis, 91 

examination  of,  60 

hallucinations  of,  650 
Sign  of  Romberg,  397 
Signal  symptom,  31,  181 


Simulo  in  epilepsy,  722 
Sinus  thrombosis,  220 
infective,  222 
cavernous,  223 
lateral,  224 
longitudinal,  225 
symptoms  of,  223 
treatment  of,  225 
marantic,  221 
diagnosis  of,  221 
prognosis  of,  222 
symptoms  of,  221 
Sinuses,  cerebral,  anatomy  of,  219 
Sixth  nerve,  anatomical  considerations  of, 
103 
effect  of  division  of,  104 
Skin,  anomalies  of,  633 

trophic  disturbances  of,  37 
Sleep,  conditions  favoring,  593 
disorders  of,  591 
drunkenness,  596 
importance  of,  in  diagnosis,  23 
palsies,  598 
palsy,  280 

physical  features  of,  591 
ptosis,  598 

requirements  for,  592 
Sleeping  sickness,  598 
Smell,  examination  of,  64 
hallucinations  of,  650 
illusions  of,  654 
loss  of,  94 
Sodium  iodid   in  cerebrospinal  syphilis, 

452 
Softening,    cerebral,    210.       See   Cerebral 
softening 
of  brain,  210 
Somnambulism,  595 
Somnolentia,  596 
Sounds,  subjective,  63 
Space  sense,  disturbance  of,  64 
Spasm,  clonic,  30 
facial,  116 

from  cord-lesions,  323 
hypoglossal,  143 
hysterical  rhythmical,  557 
laryngeal,  133 
lingual,  143 
masticatory,  110 
occupation,  521 
of  ocular  muscle,  108 
of  spinal  accessory  nerve,  149 
pharyngeal,  130 
tonic,  30 
Spasmodic    asthma,    134.       See  Asthma, 
bronchial 
tabes,  421 
torticollis,  140 
wryneck,  140 
Spasmogenic  point  or  zone,  546 
Spasms,  30 
Spastic  paraplegia,  hereditary,  431.     See 

Hereditary  spastic  paraplegia 
Special  senses,  examination  of,  60 
Speech,  anomalies  of,  634 
center  for,  160 
centers  for,  164 


INDEX. 


839 


Speech,  examination  of,  05 
Sphincter  reflex,  36 
Spina  bifida,  354 

diagnosis  of,  355 
etiology  of,  355 
occulta,  354 
prognosis  of,  355 
symptoms  of,  355 
treatment  of,  355 
Spinal  accessory  nerve,    anatomical   con- 
siderations of,  140 
paralysis  of,  1 42 
spasm  of,  140 
arteries,  anterior,  318 

posterior,  322 
cord,  anatomical  considerations  of,  316 
circulation  in,  318 
combined  scleroses  of,  421 
glioma  of,  351 
hemorrhage  into,  330 
indiscriminate  lesions  of,  330 
lesions  of,  from  pernicious  anemias, 
350 
of  gray  matter  of,  356 
of,  in  tabes  dorsalis,  394 
of,  localization  of,  vertical,  323 
of,  location  of  anesthesia  in,  51 
of,  motor  symptoms  of,  323 
of  one  lateral  half  of,  effects  of,  51, 

55 
of,  reflexes  in,  325 
of,  sensory  symptoms  of,  325 
of,  trophic  conditions  in,  326 
of,  vasomotor  disturbance  in,  326 
of,  vertical  localization  of,  323 
of,  visceral  symptoms  in,  326 
of  white  matter  of,  389 
localization  in,  316 
relation  of  lesions  of,  to  diseases  of, 
328 
of,  to  body  surface,  317  . 
of,  to  vertebrae,  317 
segments,  relation  of  anesthesia  to,  51 

of,  to  cutaneous  areas,  54,  57 
symptoms,  functions  of,  324 
syphilis  of,  450.     See  Syphilis,  spinal 
thrombotic  softening  of,  333 
transverse  sections  of,  319 
traumatic  lesions  of  substance  of, 

330 
tumors  of,  350 
douche,  687 
leptomeningitis,  acute,  262 

chronic,  266 
meningeal  hemorrhage,  266 
meninges,  tumors  of,  350 
meningitis,  260 
nerves,  division  of,  269 

histological  changes  in,  269 
muscular  symptoms  of,  270 
symptoms  of,  269 
treatment  of,  270 
injuries  and  diseases  of,  268 
lesions  of,  iu  tabes  dorsalis,  392 
special  lesions  of,  278 
pachymeningitis,  260 
stretching  in  family  ataxia,  431 


Spinal  stretching  in  tabes  dorsalis,  418 
symptoms  in  tubercular  leptomeningi- 
'  tie,  92 
syphilis,  450.     See  Syphilis,  spinal 

tumors,  350 
course  of,  352 
diagnosis  of,  '■>'>'■', 
location  of,  '■'-'>■> 
morbid  anatomy  of,  351 
prognosis  of,  353 
reflexes  in,  352 
symptoms  of,  352 
treatment  of,  353 
Spine,  concussion  of,  581 
Sporadic  cretinism,  467 
Spurious  ankle-clonus,  36 
Scpuamosal  point.  163 
Squint,  importance  of,  61 
St.  Vitus'  dance,  499 
Stah  1  ear,  No.  1,  628,  629 

No.  2,  629 
Stammering,  66 
Static  ataxia,  29 
Status  epilepticus,  571 
Steeple-shaped  skull,  616 
Stereotyped  movements,  663,  670 
Sthenic  loss  in  cerebellar  disease,  179 
Stigmata  hereditatis,  612 

of  degeneracy  in  nervous  disease,  21 

of  degeneration  in  insanity,  612 
Stimulants  in  leptomeningitis,  85 
"Stoppage,"  300 
Storm  center,  181 
Strain,  physical  and  mental,  in  etiology 

of  insanity,  634 
Stream  of  thought,  actious  induced  by 

disorders  of,  670 
Streptococcus  in  leptomeningitis,  77 
"  Stroke,"  apoplectic,  198 
Strophauthus  in  exophthalmic  goiter,  481 
Struma  exophthalmica,  472 
Strychnin  in  anterior  poliomyelitis,  363 

in  brain-tumor,  245 

in  bronchial  asthma,  135 

in  cerebral  hemorrhage,  208 

in  cerebral  softening,  218 

in  chorea,  509 

iu  exophthalmic  goiter,  481 

in  nervous  deafness,  126 

in  neuralgia,  590 

in  neurasthenia,  537 

in  neuritis,  275 

in  polio-encephalitis  superior  chronica, 
148 
Stupiditas,  728 
Stupor,  663 
Stuttering,  66 
Sul  phonal  in  chorea,  509 

in  mania,  700 
Syllable  stumbling,  66 
Symelus,  632 

Symmetrical  lipomatosis,  488 
Sympathetic  nerve,  effect  of  division  of, 

104 
Symptom,  extension,  181 

group  of  Weber,  107 

invasion,  181 


840 


INDEX. 


Symptom,  Eomberg,  29 

signal,  31,  181 
Symptomatic  disorders,  586 
Symptoms  at  a  distance,  184 
diffused,  182 
localized,  182 
Syndactyly,  632 
Syndrome,  Weber's,  177 
Synergy,  28 
Syphilis,  cerebral,  444 
arterial  form  of,  447 
diagnosis  of,  448 
general  symptoms  of,  445 
gummatous  form  of,  448 
meningeal  form  of,  446 
mental  symptoms  of,  448 
prognosis  of,  449 
special  symptoms  of,  446 
treatment  of,  449,  452 
hereditary  cerebrospinal,  452 
iu  etiology  of  insanity,  638 
inherited,  predisposing  to  nervous  dis- 
ease, 18 
of  cranial  nerves,  445 
of  nervous  system,  442 

acquired,  443 

spinal,  diagnosis  of,  452 

prognosis  of,  452 

treatment  of,  452 

Syphilitic  ataxic  paraplegia,  451 

cerebral  arteritis,  444 

meningitis,  444 
cerebritis,  444 
meningomyelitis,  450 
mental  disease,  448 
myelitis,  451 
neuritis,  452 
pseudoparesis,  448 
softening  of  cord,  451 
spinal  meningitis,  450 

paralysis,  451 
tumors  of  brain,  236 
Syphilophobia,  448 
Syringomyelia,  364 
anesthesia  in,  367 
arthropathies  in,  368 
atrophy  in,  368 
clinical  forms  of,  369 
course  of,  369 
diagnosis  of,  370 
etiology  of,  364 
morbid  anatomy  of,  365 
Mor van's  type  of,  369 
motor  disturbances  in,  368 
prognosis  of,  370 
sensory  disturbances  in,  366 
symptoms  of,  366 
treatment  of,  370 
trophic  features  of,  368 
unusual  symptoms  of,  369 
vasomotor  symptoms  of,  369 
Syringomyelic  dissociation,  367 
Subdural  space,  70 
Subjective  sounds,  hearing  of,  63 
Suicidal  tendencies,  management  of,  692 
Sulphonal  in  insanity,  690 
Suprascapular  nerve,  lesions  of,  279 


Tabes,  combined,  421 
dorsal  is,  390 

amyotrophia  in,  413 

analgesia  in,  400 

ataxia  in,  397 

auditory  symptoms  in,  404 

bones  in,  410 

cerebral  disturbances  in,  413 

constipation  in,  406 

course  of,  415 

cramps  in,  400 

crises  in,  405 

diagnosis  of,  416 

diarrhea  in,  406 

differential  diagnosis  of,  416 

disorders  of  generative  function  in., 
407 
of  intestines  in,  406 
of  nutrition  in,  409 
of  osseous  system  in,  409 
of  respiratory  apparatus  in,  408 
of  skin  in,  412 
of  stomach  in,  405 
of  urinary  apparatus  in,  406 
of  vascular  apparatus  in,  408 

disturbance  of  reflexes  in,  402 

etiology  of,  390 

gastric  crises  in,  405 

girdle  sensation  in,  400 

glycosuria  in,  407 

herpes  zoster  in,  412 

hyperalgesia  in,  401 

impotence  in,  407 

involuntary  movements  in,  398 

laryngeal  crises  in,  408 
stroke  in,  408 

lightning  pains  in,  399 

morbid  anatomy  of,  392 

motor  disturbances  in,  396 

muscular  atrophies  in,  413 

nephritic  crises  in   407 

optic  nerve  in,  403 

pains  in,  399 

palsies  in,  399 

perforating  ulcer  in,  412 

pharyngeal  crises  in,  408 

prognosis  of,  417 

ptosis  in,  403 

pupils  in,  403 

rarefying  osteitis  in ,  410 

Robertson's  sign  in,  403 

Romberg's  sign  in,  397 

sensory  disturbances  in,  399 

spontaneous  fractures  in,  409 

squint  in,  403 

symptoms  of,  396 
tabulation  of,  414 

tabetic  arthropathy  in,  410 

treatment  of,  417 

trophic  cutaneous  disorders  in,  412 
disorders  in,  409 

valvular  disease  in,  408 

varieties  of,  415 

visceral  disorders  in,  405 

visual  disturbances  in,  402 

vomiting  in,  405 

Westphal's  sign  in,  402 


INDEX. 


841 


Tabes,  spasmodic,  421 

Tabetic  arthropathy,  410 
crises,  405 

cuirass,  405 
fractures,  409 

joint,  411 
Tache  cerebrale  iu  leptomeningitis,  80 

in  tubercular  leptomeningitis,  91 
Tachycardia,  136 
Tactile  sense,  49 
testing  of,  49 
Taste,  center  for,  162 

electrical  testing  of,  47 

examination  of,  64 

hallucinations  of,  650 

illusions  of,  654 

in  facial  paralysis,  119 

loss  of,  64 

perversions  of,  65 

subjective  sensations  of,  65 
Teeth,  anomalies  of,  626 
Temperature  changes  in  insanity,  675 

examination  of,  24 

in  anterior  poliomyelitis,  359 

in  cerebral  hemorrhage,  199 

in  leptomeningitis,  81 

in  spinal  leptomeningitis,  264 

in  tubercular  leptomeningitis,  90 

localized  elevation  of,  as  a  symptom  in 
brain  disease,  184 
Tenderness  as  a  symptom,  55 

as  a  symptom  of  brain  disease,  184 

in  leptomeningitis,  80 

in  multiple  neuritis,  304 

in  sciatic  neuritis,  291 
Tender  points  in  sciatic  neuritis,  292 

of  Valleix,  587 
Tendon-reflexes  in  leptomeningitis,  82 

in  tubercular  leptomeningitis,  90 
Tendons,  trophic  disorders  of,  38 
Teratoma  of  brain,  236 
Terminal  dementia,  609 
Tetanella,  495.     See  Tetany 
Tetanus,  490 

cathodal  closing,  43 

cephalic,  491 

diagnosis  of,  491 

etiology  of,  490 

head,  491 

hydrophobicus,  491 

morbid  anatomy  of,  490 

neonatorum,  491 

prognosis  of,  491 

puerperal,  491 

symptoms  of,  490 

treatment  of,  492 

varieties  of,  491 
Tetany,  495 

course  of,  497 

diagnosis  of,  498 

etiology  of,  495 

prognosis  of,  498 

symptoms  of,  496 

treatment  of,  498 
Thermic  sense,  testing  of,  50 
Thermo-analgesia,  50 
Thermo-anesthesia,  50 


Third    nerve,  affection  of,  in  leptomenin- 
gitis, 80 
anatomical  considerations  of,  103 

effect  of  division  of,  104 
Thomsen's  disease,  519 
diagnosis  of,  521 
etiology  of,  519 
morbid  anatomy  ef,  519 
symptoms  of,  519 
treatment  of,  521 
Thoracic  nerve,  posterior  lesions  of,  279 
Thought-inhibition,  663 
Thrombosis  a  cause  of  cerebral  softening, 
210-218 

of  arteries  of  spinal  cord,  333 

of  sinus,  220.     .See  Sinus  thrombosis 
Thrombotic  softening  of  spinal  cord,  333 
Thyroidin,  472 
Thyroid  treament,  471 
Tic,  583 

douloureux,  30,  584 

etiology  of,  584 

treatment  of,  585 
Tics,  583 

Tinnitus,  124,  125 
Toes,  center  for  movements  of,  160 
Tongue,  anomalies  of,  626 

motor  center  for,  158 

paralysis  of.  144 
Tonic  convulsions,  31 

excess  in  cerebellar  disease,  179 

spasm,  30 
Topical  symptoms  in  brain  disease,  183 
Torticollis,  mental,  141,  584 

spasmodic,  140 
Torus  palatinus,  622,  626 
Toxic  influences  in  etiology  of  insanity, 

635 
Trance,  hysterical,  554 
Transitory  mania,  697 
Transverse  myelitis,  334 
Traumatic  neuromata,  276 

neuroses,  581 
Tremor,  fibrillary,  29 

handwriting  in,  30 

importance  of,  29 

intention,  29 

testing  for,  29 

volitional,  29 
Tremors,  29 
Trephining  in  cerebral  hemorrhage,  208 

in  leptomeningitis,  86 
Triceps  reflex,  33 

Trifacial  nerve,  anatomical  considerations, 
of,  109 
cortical  diseases  of,  110 
disease  of  branches  of,  113 
diseases  of,  109 
nuclear  disease  of,  111 

neuralgia,  589 

neuritis,  113 

peripheral  intracranial  affections  of,  111 
Trigeminus.     See  Trifacial  nerve 
Trigonocephalus,  617 
Trinitrin  in  angina  pectoris,  139 

in  Raynaud's  disease,  485 
Trional  in  chorea,  509 


842 


INDEX. 


Trional  in  epilepsy,  576 
in  insauity,  690 
in  mania,  700 
in  neurasthenia,  538 
Trismus,  490 
Trochanteric  point,  292 
Trophic  conditions,  37 

disorders  in  insanity,  673 
Trophoneuroses,  457 
Trousseau's  sign  of  tetany,  497 
Trunk,  center  for  movements  of,  160 

nerves  of,  lesions  of,  288 
Tubercle  of  brain,  234 
Tubercular  leptomeningitis,  88.     See  Lep- 
tomeningitis 
meningitis,    88.       See   Leptomeningitis, 
tubercular 
Tuberculosis  in  etiology  of  insanity,  639 
Tumor  of  brain,  course  of,  240 
Tumors  of  brain,  233 
diagnosis  of,  241 
etiology  of,  233 
pathological  anatomy  of,  234 
prognosis  of,  243 
symptoms  of,  237 
syphilitic,  236 
treatment  of,  243 
of  nerves,  275.     See  also  Neuromata 
of  spinal  cord,  350 
meninges,  350 
Tuning-fork  in  testing  hearing,  63 
Turkish  baths  in  multiple  neuritis,  315 
Twelfth  cranial  nerve.      See  Hypoglossal 

nerve 
Typhoid  bacillus  in  leptomeningitis,  77 


Ulnae  nerve,  lesions  of,  283 
Unorientation,  661 
Unsymmetrical  hypertrophies,  489 
Upper  extremity,  center  for  motions  of,  159 
Urine,  condition  of,  25 

in  insanity,  674 

in  leptomeningitis,  82 
Urticaria,  giant,  486 

in  leptomeningitis,  81 


Vagus,  anatomical  considerations  of,  129 

cardiac  branches  of,  136 

diseases  of,  130 

gastric  branches  of,  139 

laryngeal  branches  of,  130 

pharyngeal  branches  of,  130 

pulmonary  branches  of,  134 
Valerian  in  myoclonia,  513 
Valleix,  tender  points  of,  587 
Vascular  disorders  in  insanity,  676 
Veins,  cerebral,  anatomy  of,  219 
Venereal  history,  importance  of,  in  diag- 
nosis of  nervous  disease,  19 
Venesection  in  cerebral  hemorrhage,  208 
Veratrum  in  cerebral  hemorrhage,  208 

viride  in  hematomyelia,  333 
Verbigeration,  664,  695 
Verrucktheit,  603 


Vertebral  segments,  relation  of  maximal 

points  of  pain  to,  57 
Vertical  localization  of  a  cord-lesion,  323 

point,  163 
Vertigo  as  a  symptom,  182 

aural,  126.     See  Aural  vertigo 

in  cerebellar  disease,  179 

in  disease  of  labyrinth,  63 

in  tumor  of  brain,  239 
Vestibular  nerve,  irritation  of,  126 
Violence  in  insane,  management  of,  693 
Virile  reflex,  407 

Visceral  disease,  relation  of  areas  of  pain 
to,  56 

pia,  70 
Vision,  center  for,  161 

electrical  testing  of,  47 

illusions  of,  653 

in  multiple  neuritis,  304 

testing  of,  61 
Visual  aphasia,  170 

field,  61 

in  nervous  diseases,  62 
testing  of,  62 

tract,  95 
Volitional  tremor,  29 
Vomiting  as  a  cerebral  symptom,  183 

in  leptomeningitis,  79 

in  lesions  of  spinal  cord,  326 

in  tabes  dorsalis,  405 

in  tubercular  leptomeningitis,  99 

in  tumor  of  brain,  239 

projectile,  as  a  symptom,  183 


Wahnsinn,  603 
Wasting  palsy,  371 

Weakness,  muscular,  in  leptomeningitis, 
80 
of  judgment,  668 
Weber,  symptom  group  of,  107 

syndrome,  177 
Weber's  test,  405 

Wernicke's    hemianopic    pupillary  reac- 
tion, 98 
sign,  32 
Westphal's  sign.  402 
Whisky  in  angina  pectoris,  139 
White  cerebral  softening,  211 

matter  of  cord,  lesions  of,  389 
Wildermuth's  Aztec  ear,  629 

ear,  629,  631 
Word-blindness,  explanation  of  production 
of,  98 
lesion  causing,  161 
Word- centers,  164 
Word-deafness,  125,  168 

lesion  causing,  162 
Word  memories,  164 
stability  of,  166 
storage  of,  165 
Wormian  bones,  significance  of,  619 
Wrist,  center  for  movements  of,  160 
Wrist-clonus,  34 
Writer's  cramp,  522 
course  of,  526 
diagnosis  of,  526 


INDEX. 


843 


Writer's  cramp,  etiology  of,  522 
motor  disorders  of,  523 
pathology  of,  522 
prognosis  of,  526 
sensory  disorders  in,  526 
symptoms  of,  523 


Writer's  cramp,  treatment  of,  527 
Written  speech,  perception  of,  67 
Wryneck,  spasmodic,  1  10 


5TELLOW  cerebral  softening,  211 


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